Provider Demographics
NPI:1548515554
Name:KOSTINER, SHELLY DIANE (NP)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:DIANE
Last Name:KOSTINER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 N LISMORE CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9434
Mailing Address - Country:US
Mailing Address - Phone:757-287-4971
Mailing Address - Fax:
Practice Address - Street 1:17 LANGLEY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23681-4430
Practice Address - Country:US
Practice Address - Phone:757-864-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170176363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health