Provider Demographics
NPI:1043746860
Name:COSTALES, GENNIFER
Entity type:Individual
Prefix:
First Name:GENNIFER
Middle Name:
Last Name:COSTALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GENNIFER
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:75 HOOD RD
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603
Mailing Address - Country:US
Mailing Address - Phone:787-890-8477
Mailing Address - Fax:
Practice Address - Street 1:75 HOOD RD
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00603
Practice Address - Country:UM
Practice Address - Phone:787-890-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider