Provider Demographics
NPI:1679815427
Name:DECOSTA, JETTAYA TIES'E (RN)
Entity Type:Individual
Prefix:MS
First Name:JETTAYA
Middle Name:TIES'E
Last Name:DECOSTA
Suffix:
Gender:F
Credentials:RN
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 1634
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-0604
Mailing Address - Country:US
Mailing Address - Phone:631-494-8488
Mailing Address - Fax:
Practice Address - Street 1:124 OLD QUOGUE RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3941
Practice Address - Country:US
Practice Address - Phone:631-494-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313600-1164W00000X
NY768677163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse