Provider Demographics
NPI:1689227100
Name:COSTA, MARA KELLY (APRN-BC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:KELLY
Last Name:COSTA
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 W HORIZON RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2729
Mailing Address - Country:US
Mailing Address - Phone:702-247-9994
Mailing Address - Fax:702-651-9995
Practice Address - Street 1:2430 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2729
Practice Address - Country:US
Practice Address - Phone:702-247-9994
Practice Address - Fax:702-651-9995
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV822306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner