Provider Demographics
NPI:1407929581
Name:COSTA, CHRISTINE (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 ARGONNE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3231
Mailing Address - Country:US
Mailing Address - Phone:562-434-6007
Mailing Address - Fax:562-856-2370
Practice Address - Street 1:800 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3547
Practice Address - Country:US
Practice Address - Phone:657-278-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA568972163WC0400X
CA14122363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management