Provider Demographics
NPI:1225444656
Name:COSTELLO, RYAN VINCENT (RN)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:VINCENT
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S. 2ND ST.
Mailing Address - Street 2:APT A
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714
Mailing Address - Country:US
Mailing Address - Phone:516-622-1547
Mailing Address - Fax:
Practice Address - Street 1:68 S. 2ND ST.
Practice Address - Street 2:APT A
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714
Practice Address - Country:US
Practice Address - Phone:516-622-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682448-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse