Healthcare Provider Details

I. General information

NPI: 1609395102
Provider Name (Legal Business Name): ANDREA KOSTY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 10/24/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2088 NE KIM LN
BEND OR
97701-6588
US

IV. Provider business mailing address

2088 NE KIM LN
BEND OR
97701-6588
US

V. Phone/Fax

Practice location:
  • Phone: 541-309-0031
  • Fax:
Mailing address:
  • Phone: 541-309-0031
  • Fax: 970-382-0328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10028481
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1638787
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: