Provider Demographics
NPI:1023172673
Name:KOSTYO, REBECCA JO (APRN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:KOSTYO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4130 DUTCHMANS LN
Mailing Address - Street 2:STE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4713
Mailing Address - Country:US
Mailing Address - Phone:502-897-1794
Mailing Address - Fax:502-238-1286
Practice Address - Street 1:4130 DUTCHMANS LN
Practice Address - Street 2:STE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4713
Practice Address - Country:US
Practice Address - Phone:502-897-1794
Practice Address - Fax:502-238-1286
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004449363L00000X
IN71006195A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201289910Medicaid
000000641811OtherNRP/ANTHEM
000052152ZOtherNOTC/HUMANA
KY7100099350Medicaid
3764310000OtherNOTC/PAD
000000643662OtherNOTC/ANTHEM
110584OtherNOTC./SIHO
50027236OtherNOTC/PHP
9769702OtherNRP/CIGNA
50027236OtherNOTC/PHP
110584OtherNOTC./SIHO
IN201289910Medicaid
000000643662OtherNOTC/ANTHEM