Provider Demographics
NPI:1417085846
Name:COSTELLA, CAROLYN S (MSN APRN BC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:S
Last Name:COSTELLA
Suffix:
Gender:F
Credentials:MSN APRN BC
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Mailing Address - Street 1:1289 ROUTE 38
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-2730
Mailing Address - Country:US
Mailing Address - Phone:609-267-5656
Mailing Address - Fax:609-265-1895
Practice Address - Street 1:1289 ROUTE 38
Practice Address - Street 2:SUITE 203
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2730
Practice Address - Country:US
Practice Address - Phone:609-267-5656
Practice Address - Fax:609-265-1895
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00041700363L00000X
NJ26NR10857800163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0183946Medicaid