Provider Demographics
NPI:1821195611
Name:DACOSTA, NICHOLE A (NP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:A
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 2ND AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 2ND AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2820
Practice Address - Country:US
Practice Address - Phone:781-507-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242032363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP529002Medicare PIN