Healthcare Provider Details

I. General information

NPI: 1578116042
Provider Name (Legal Business Name): MARIA JOSEPHINA CIRCOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEALTH CENTER DR
BRIDGEWATER VA
22812-9511
US

IV. Provider business mailing address

100 HEALTH CENTER DR
BRIDGEWATER VA
22812-9511
US

V. Phone/Fax

Practice location:
  • Phone: 540-828-2634
  • Fax:
Mailing address:
  • Phone: 540-828-2634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001265370
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024177933
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: