Provider Demographics
NPI:1548765563
Name:COSTA-STEPHENSON, GRAZIELLA
Entity Type:Individual
Prefix:
First Name:GRAZIELLA
Middle Name:
Last Name:COSTA-STEPHENSON
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 1:4724 CHARLOTTE HWY
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8095
Mailing Address - Country:US
Mailing Address - Phone:803-831-1911
Mailing Address - Fax:
Practice Address - Street 1:4724 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-8095
Practice Address - Country:US
Practice Address - Phone:803-831-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21840363LF0000X
NC5010366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5010366OtherNC LICENSE
SC21840OtherSC LICENSE