Provider Demographics
NPI:1538718952
Name:COSTA, CARRIE ANN MI (CNM)
Entity type:Individual
Prefix:
First Name:CARRIE ANN
Middle Name:MI
Last Name:COSTA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LITCHFIELD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3517
Mailing Address - Country:US
Mailing Address - Phone:203-901-3695
Mailing Address - Fax:
Practice Address - Street 1:60 WESTWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2460
Practice Address - Country:US
Practice Address - Phone:203-578-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT459367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT459OtherCNM LICENSE