Provider Demographics
NPI:1477906873
Name:COSTLOW, AMANDA S
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:COSTLOW
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 1:437 ROSEWOOD AVE SE # 2
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2825
Mailing Address - Country:US
Mailing Address - Phone:740-739-1797
Mailing Address - Fax:
Practice Address - Street 1:437 ROSEWOOD AVE SE # 2
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2825
Practice Address - Country:US
Practice Address - Phone:740-739-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other