Provider Demographics
NPI:1447609136
Name:COSTANZO, ROBERTA DIANNE
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:DIANNE
Last Name:COSTANZO
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 1:37 EASTFIELD LN
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-1606
Mailing Address - Country:US
Mailing Address - Phone:631-848-3050
Mailing Address - Fax:
Practice Address - Street 1:37 EASTFIELD LN
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-1606
Practice Address - Country:US
Practice Address - Phone:631-848-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401051-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health