Provider Demographics
NPI:1306422464
Name:KOSTMAYER, ERICA ALEXANDER (CRNP)
Entity type:Individual
Prefix:MS
First Name:ERICA
Middle Name:ALEXANDER
Last Name:KOSTMAYER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COWAN RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2022
Mailing Address - Country:US
Mailing Address - Phone:228-202-1144
Mailing Address - Fax:
Practice Address - Street 1:401 COWAN RD UNIT B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2022
Practice Address - Country:US
Practice Address - Phone:228-202-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-156402363LP0200X
MS904935363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics