Healthcare Provider Details

I. General information

NPI: 1902617616
Provider Name (Legal Business Name): KANOELANI COSTALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S FRETZ AVE STE C
EDMOND OK
73003-5568
US

IV. Provider business mailing address

19501 N PENNSYLVANIA AVE
EDMOND OK
73012-4802
US

V. Phone/Fax

Practice location:
  • Phone: 405-757-7980
  • Fax:
Mailing address:
  • Phone: 702-448-0577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: