Healthcare Provider Details

I. General information

NPI: 1083101174
Provider Name (Legal Business Name): STEPHANIE MARIE COSTA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 TOLL GATE RD
WARWICK RI
02886-2799
US

IV. Provider business mailing address

175 PARAMOUNT DR UNIT 203
RAYNHAM MA
02767-1066
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-4800
  • Fax: 401-738-8153
Mailing address:
  • Phone: 774-320-3040
  • Fax: 508-910-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN01808
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: