Provider Demographics
NPI:1558842245
Name:COSTA, LAURA (APRN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N US HIGHWAY 441 STE 912
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6811
Mailing Address - Country:US
Mailing Address - Phone:352-750-1277
Mailing Address - Fax:844-388-6186
Practice Address - Street 1:1400 N US HIGHWAY 441 STE 912
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6811
Practice Address - Country:US
Practice Address - Phone:352-750-1277
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000025805363LF0000X
FLAPRN9363460363LF0000X
FLF08180110363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily