Provider Demographics
NPI:1639445562
Name:COSTANZA, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:COSTANZA
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 1:610 REESE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:NY
Mailing Address - Zip Code:13340-3404
Mailing Address - Country:US
Mailing Address - Phone:315-895-3007
Mailing Address - Fax:315-895-4102
Practice Address - Street 1:610 REESE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:NY
Practice Address - Zip Code:13340-3404
Practice Address - Country:US
Practice Address - Phone:315-895-3007
Practice Address - Fax:315-895-4102
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292422-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool