Provider Demographics
NPI:1376337204
Name:COSSIO, NANETTE
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:
Last Name:COSSIO
Suffix:
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 1:165 AUSTIN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-4360
Mailing Address - Country:US
Mailing Address - Phone:305-815-0398
Mailing Address - Fax:
Practice Address - Street 1:475 W TOWN PL STE 105
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3649
Practice Address - Country:US
Practice Address - Phone:904-680-7328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA97000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist