Provider Demographics
NPI:1376858753
Name:COSTELLO, CHERYL JANE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:JANE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 THORNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9313
Mailing Address - Country:US
Mailing Address - Phone:563-332-4365
Mailing Address - Fax:
Practice Address - Street 1:833 16TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3808
Practice Address - Country:US
Practice Address - Phone:309-764-6744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004681314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility