Provider Demographics
NPI:1083484398
Name:COSTELLO, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:COSTELLO
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 1:3226 TOWN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2167
Mailing Address - Country:US
Mailing Address - Phone:727-237-5271
Mailing Address - Fax:
Practice Address - Street 1:3404 N LECANTO HWY STE D
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3569
Practice Address - Country:US
Practice Address - Phone:352-419-4856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program