Provider Demographics
NPI:1518229814
Name:COSTA, KIMBERLY
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
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 1:175 VOGEL AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3030
Mailing Address - Country:US
Mailing Address - Phone:908-623-7500
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE # 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3409
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY871641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist