Provider Demographics
NPI:1003850405
Name:COSTELLO, JACQUELINE R (DNP, RN, CPNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DNP, RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2150 HERBERT CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3736
Practice Address - Country:US
Practice Address - Phone:252-744-5437
Practice Address - Fax:252-744-1514
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9223611363L00000X
TX760023363LP0200X
NC5006348363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1003850405Medicaid
NCNCF6190322Medicare PIN