Provider Demographics
NPI:1821069428
Name:COSTELLIC, SHERI DARLENE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SHERI
Middle Name:DARLENE
Last Name:COSTELLIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 CAMINO DE LA REINA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3240
Mailing Address - Country:US
Mailing Address - Phone:619-688-3079
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER
Practice Address - Street 2:34800 BOB WILSONDR. SUITE409
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1409
Practice Address - Country:US
Practice Address - Phone:619-532-9000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1145367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered