Provider Demographics
NPI:1083796825
Name:KOSTENBAUDER, MARY KAREN (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAREN
Last Name:KOSTENBAUDER
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 BURL WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4253
Mailing Address - Country:US
Mailing Address - Phone:407-325-5075
Mailing Address - Fax:
Practice Address - Street 1:9950 BURL WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4253
Practice Address - Country:US
Practice Address - Phone:407-325-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP641142363LA2200X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTH000Medicare UPIN
FLY5940Medicare ID - Type Unspecified