Provider Demographics
NPI:1518468743
Name:COSTA, JAHAIRA (LVN)
Entity Type:Individual
Prefix:
First Name:JAHAIRA
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JAHAIRA
Other - Middle Name:
Other - Last Name:CORPORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:11049 W HOFFMAN DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79764-9043
Mailing Address - Country:US
Mailing Address - Phone:432-385-7790
Mailing Address - Fax:
Practice Address - Street 1:11049 W HOFFMAN DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-9043
Practice Address - Country:US
Practice Address - Phone:432-385-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323051164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse