Provider Demographics
NPI:1366859324
Name:COSTELLO, MERCEDES N
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:N
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 HUNTINGTON DR APT B
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4833
Mailing Address - Country:US
Mailing Address - Phone:949-689-0950
Mailing Address - Fax:
Practice Address - Street 1:2502 E. HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2221
Practice Address - Country:US
Practice Address - Phone:626-280-6510
Practice Address - Fax:626-288-1026
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program