1053765404 NPI number — CAROL ANN KOSTELLA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053765404 NPI number — CAROL ANN KOSTELLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSTELLA
Provider First Name:
CAROL
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAPLE
Provider Other First Name:
CAROL
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD, LDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053765404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3724 LOYOLA DRIVE
Provider Second Line Business Mailing Address:
APT. 141
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-402-1190
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3724 N LOYOLA DR APT 141
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-7738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-402-1190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  709045 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133V00000X , with the licence number: 259 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 709045 . This is a "REGISTRATION - ACADEMY OF NUTRITION AND DIETETICS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 259 . This is a "STATE OF LOUISIANA LICENSURE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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