Provider Demographics
NPI:1326239195
Name:COSTELLO GARD, LIBBY A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LIBBY
Middle Name:A
Last Name:COSTELLO GARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4008
Mailing Address - Country:US
Mailing Address - Phone:406-327-1918
Mailing Address - Fax:406-549-2246
Practice Address - Street 1:1211 S RESERVE ST STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3103
Practice Address - Country:US
Practice Address - Phone:406-327-3057
Practice Address - Fax:406-327-3231
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099007632RN163WP2201X
OR200850014NP363LF0000X
MTNUR-APRN-LIC-126782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616442Medicaid
OR500616442Medicaid
ORR161346Medicare PIN
ORR161347Medicare PIN
ORR161348Medicare PIN
ORR161344Medicare PIN
ORR161345Medicare PIN
ORR161343Medicare PIN