Provider Demographics
NPI:1245609395
Name:COSTA, CRYSTAL JEAN NICOLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JEAN NICOLE
Last Name:COSTA
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 1:4732 DUNDEE ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9449
Mailing Address - Country:US
Mailing Address - Phone:925-421-8429
Mailing Address - Fax:
Practice Address - Street 1:4732 DUNDEE ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-9449
Practice Address - Country:US
Practice Address - Phone:925-421-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029245163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult