Provider Demographics
NPI:1649244997
Name:COSTANZO, ERIN R (APRN FNPC)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:R
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:APRN FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180
Mailing Address - Country:US
Mailing Address - Phone:770-459-4411
Mailing Address - Fax:770-459-2424
Practice Address - Street 1:7869 VILLA RICA HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157
Practice Address - Country:US
Practice Address - Phone:770-459-4411
Practice Address - Fax:770-459-2424
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146776NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA453616500AMedicaid
GA453616500BMedicaid
GA453616500BMedicaid
GA453616500AMedicaid