Provider Demographics
NPI:1356657746
Name:COSTELLO, CARLA C (FNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:C
Last Name:COSTELLO
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 1:320 N HOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-2140
Mailing Address - Country:US
Mailing Address - Phone:318-559-2404
Mailing Address - Fax:318-559-2430
Practice Address - Street 1:320 N HOOD ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-2140
Practice Address - Country:US
Practice Address - Phone:318-559-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN095103 AP06260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2121286Medicaid
LAAP06260OtherSTATE LICENSE