Provider Demographics
NPI:1407553761
Name:COSTELLO, KEITH THOMAS (FNP)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:THOMAS
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 SW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7422
Mailing Address - Country:US
Mailing Address - Phone:352-873-9557
Mailing Address - Fax:352-873-1842
Practice Address - Street 1:3310 SW 34TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7422
Practice Address - Country:US
Practice Address - Phone:352-873-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11024420363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner