Provider Demographics
NPI:1982959847
Name:COSTON, KELLY L
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:COSTON
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 1:4421 HUCKLEBERRY RD.
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405
Mailing Address - Country:US
Mailing Address - Phone:910-523-5314
Mailing Address - Fax:
Practice Address - Street 1:4421 HUCKLEBERRY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8470
Practice Address - Country:US
Practice Address - Phone:910-523-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7600224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant