Provider Demographics
NPI:1174267793
Name:COSTELLO, MELISSA W (RRT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:W
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LAUREN
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RRT
Mailing Address - Street 1:526 EVOLVE DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4693
Mailing Address - Country:US
Mailing Address - Phone:919-262-6088
Mailing Address - Fax:
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-8801
Practice Address - Country:US
Practice Address - Phone:910-296-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6683227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered