Provider Demographics
NPI:1053765404
Name:KOSTELLA, CAROL ANN
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:KOSTELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:CAPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LDN
Mailing Address - Street 1:3724 LOYOLA DRIVE
Mailing Address - Street 2:APT. 141
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-402-1190
Mailing Address - Fax:
Practice Address - Street 1:3724 N LOYOLA DR APT 141
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-7738
Practice Address - Country:US
Practice Address - Phone:504-402-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA709045133V00000X
LA259133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY709045OtherREGISTRATION - ACADEMY OF NUTRITION AND DIETETICS
LA259OtherSTATE OF LOUISIANA LICENSURE