Provider Demographics
NPI:1114433323
Name:COSTANZA, THAO L (AGPCNP)
Entity Type:Individual
Prefix:MRS
First Name:THAO
Middle Name:L
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 VINE ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-4827
Mailing Address - Country:US
Mailing Address - Phone:857-363-8776
Mailing Address - Fax:
Practice Address - Street 1:110 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5501
Practice Address - Country:US
Practice Address - Phone:617-632-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267066363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care