Basic Information
| Provider Information | |||||||||
| NPI: | 1609236553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | FERNANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ACNPC-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 208111 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.