Provider Demographics
NPI:1477299139
Name:COSTELLO, JAMIE NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 MARIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3447
Mailing Address - Country:US
Mailing Address - Phone:217-274-0787
Mailing Address - Fax:
Practice Address - Street 1:201 N RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3935
Practice Address - Country:US
Practice Address - Phone:877-974-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025184363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner