1821069428 NPI number — MS. SHERI DARLENE COSTELLIC CRNA

Table of content: MS. SHERI DARLENE COSTELLIC CRNA (NPI 1821069428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821069428 NPI number — MS. SHERI DARLENE COSTELLIC CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLIC
Provider First Name:
SHERI
Provider Middle Name:
DARLENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821069428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
934 CAMINO DE LA REINA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-3240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-688-3079
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL MEDICAL CENTER
Provider Second Line Business Practice Location Address:
34800 BOB WILSONDR. SUITE409
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92134-1409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-532-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2006

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: 367500000X , with the licence number:  1145 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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