Provider Demographics
NPI:1134317696
Name:COSTELLO, JO ANNE (RN)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ANNE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PEBBLEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-4118
Mailing Address - Country:US
Mailing Address - Phone:585-865-8404
Mailing Address - Fax:585-865-5604
Practice Address - Street 1:107 PEBBLEVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4118
Practice Address - Country:US
Practice Address - Phone:585-865-8404
Practice Address - Fax:585-865-5604
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY461476-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02406182Medicaid