Provider Demographics
NPI:1760854921
Name:COSTA, LORI-MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LORI-MARIE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 COTTAGE DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6127
Mailing Address - Country:US
Mailing Address - Phone:631-742-1163
Mailing Address - Fax:
Practice Address - Street 1:21 COTTAGE DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6127
Practice Address - Country:US
Practice Address - Phone:631-742-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236428164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse