Provider Demographics
NPI:1821797135
Name:KOSTOV, ALLA
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:KOSTOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:778-563-7748
Mailing Address - Fax:
Practice Address - Street 1:1370 E VENICE AVE STE 202
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9084
Practice Address - Country:US
Practice Address - Phone:941-480-0500
Practice Address - Fax:941-480-9322
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9554103163W00000X, 163W00000X
FLAPRN11035174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily