Provider Demographics
NPI:1336641323
Name:COSTELLO, CASSIE NOELLE (RD)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:NOELLE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 FRONT ST UNIT 21
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-7701
Mailing Address - Country:US
Mailing Address - Phone:516-404-4270
Mailing Address - Fax:888-974-8589
Practice Address - Street 1:203 FRONT ST UNIT 21
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-7701
Practice Address - Country:US
Practice Address - Phone:603-391-8206
Practice Address - Fax:888-974-8589
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1444133V00000X
MALDN5576133V00000X
RILDN00945133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered