Basic Information
| Provider Information | |||||||||
| NPI: | 1356990816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | MARIANNA | ||||||||
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| Credential: | APN/CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 NE 37TH ST | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334315925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8623778564 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5352 LINTON BLVD | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614984440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2019 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 9487244 | FL | N | Nursing Service Providers | Registered Nurse | 367500000X | 127876 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | APRN11004317 | 01 | FL | STATE LICENSE | OTHER |