Provider Demographics
NPI:1811540784
Name:ACOSTA, JULISSA MERCEDES I
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:MERCEDES
Last Name:ACOSTA
Suffix:I
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 1:26 DEPAN AVE # 1
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2227
Mailing Address - Country:US
Mailing Address - Phone:917-554-8259
Mailing Address - Fax:
Practice Address - Street 1:26 DEPAN AVE # 1
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2227
Practice Address - Country:US
Practice Address - Phone:917-554-8259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist