Provider Demographics
NPI:1487183216
Name:DECOSTA, ADRIENNE IDA (LPN)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:IDA
Last Name:DECOSTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 LANSDOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-2030
Mailing Address - Country:US
Mailing Address - Phone:631-664-4682
Mailing Address - Fax:
Practice Address - Street 1:303 LANSDOWNE AVE
Practice Address - Street 2:
Practice Address - City:CARLE PLACE
Practice Address - State:NY
Practice Address - Zip Code:11514-2030
Practice Address - Country:US
Practice Address - Phone:631-664-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210049164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse