Provider Demographics
NPI:1902617616
Name:COSTALEZ, KANOELANI
Entity type:Individual
Prefix:
First Name:KANOELANI
Middle Name:
Last Name:COSTALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19501 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4802
Mailing Address - Country:US
Mailing Address - Phone:702-448-0577
Mailing Address - Fax:
Practice Address - Street 1:425 S FRETZ AVE STE C
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5568
Practice Address - Country:US
Practice Address - Phone:405-757-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician