Provider Demographics
NPI:1992354625
Name:KOSTECKI, SUSAN SHANAHAN (RN, CNNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SHANAHAN
Last Name:KOSTECKI
Suffix:
Gender:F
Credentials:RN, CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 RAINTREE CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4653
Mailing Address - Country:US
Mailing Address - Phone:916-276-8942
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7881363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care