Provider Demographics
NPI:1063567345
Name:DACOSTA, BRENDA ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:ANN
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 PINE AVE APT 408-P
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2386
Mailing Address - Country:US
Mailing Address - Phone:562-432-0410
Mailing Address - Fax:
Practice Address - Street 1:5850 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1215
Practice Address - Country:US
Practice Address - Phone:323-846-4265
Practice Address - Fax:323-232-8115
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner