Provider Demographics
NPI:1043881568
Name:COSTALES, SUZELLE L (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SUZELLE
Middle Name:L
Last Name:COSTALES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7771 NW 7TH ST APT 902
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4014
Mailing Address - Country:US
Mailing Address - Phone:305-300-0922
Mailing Address - Fax:
Practice Address - Street 1:2400 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2919
Practice Address - Country:US
Practice Address - Phone:305-265-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily