Provider Demographics
NPI:1497092522
Name:KOSTYAK, CARRIE LYN (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYN
Last Name:KOSTYAK
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16980 DALLAS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1908
Mailing Address - Country:US
Mailing Address - Phone:972-391-1915
Mailing Address - Fax:972-391-2061
Practice Address - Street 1:16980 DALLAS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1908
Practice Address - Country:US
Practice Address - Phone:972-391-1915
Practice Address - Fax:972-391-2061
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122867363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX278852YKP5Medicare PIN