Provider Demographics
NPI:1235881145
Name:COSTON, DANNIAL RENE
Entity Type:Individual
Prefix:
First Name:DANNIAL
Middle Name:RENE
Last Name:COSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127 N STATE HWY 14 STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9461
Mailing Address - Country:US
Mailing Address - Phone:505-281-2460
Mailing Address - Fax:
Practice Address - Street 1:1202 MAIN ST NE STE A
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7421
Practice Address - Country:US
Practice Address - Phone:505-565-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily