Basic Information
Provider Information | |||||||||
NPI: | 1346622487 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COSTANZO BROWN | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COSTANZO | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 200 HYGEIA DR | ||||||||
Address2: | CCHS PHYSICIAN CONTRACTING, SUITE 2300 | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197132049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4755 OGLETOWN STANTON RD | ||||||||
Address2: | 6TH FLOOR | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197182200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027336050 | ||||||||
FaxNumber: | 3027336074 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2015 | ||||||||
LastUpdateDate: | 03/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | LG-0000815 | DE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | L1-0036412 | DE | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.