Provider Demographics
NPI:1205405719
Name:HOLMES, MICHELINE COSTA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELINE
Middle Name:COSTA
Last Name:HOLMES
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:MICHELINE
Other - Middle Name:ARAGAO
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:305 10TH ST STE 104
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-1607
Practice Address - Country:US
Practice Address - Phone:410-957-0273
Practice Address - Fax:410-957-0152
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR189395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid