Provider Demographics
NPI:1356990816
Name:COSTA, JENNA MARIANNA (APN/CRNA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIANNA
Last Name:COSTA
Suffix:
Gender:F
Credentials:APN/CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 NE 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-5925
Mailing Address - Country:US
Mailing Address - Phone:862-377-8564
Mailing Address - Fax:
Practice Address - Street 1:5352 LINTON BLVD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6514
Practice Address - Country:US
Practice Address - Phone:561-498-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9487244163W00000X
FLAPRN11004317367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11004317OtherSTATE LICENSE