Provider Demographics
NPI:1164003182
Name:COSTLOW, RAQUEL ALEXANDRA (FNP)
Entity Type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:ALEXANDRA
Last Name:COSTLOW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:RAQUEL
Other - Middle Name:ALEXANDRA
Other - Last Name:CEBALLOS MENDOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1822 ELM TRACE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4804
Mailing Address - Country:US
Mailing Address - Phone:330-727-8912
Mailing Address - Fax:
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-729-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine