Provider Demographics
NPI:1497922157
Name:COSTELLO, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:400 SOUTH ORANGE AVENUE
Mailing Address - Street 2:SETON HALL UNIVERSITY HEALTH SERVICES
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2697
Mailing Address - Country:US
Mailing Address - Phone:973-761-9175
Mailing Address - Fax:973-761-9193
Practice Address - Street 1:400 SOUTH ORANGE AVENUE
Practice Address - Street 2:SETON HALL UNIVERSITY HEALTH SERVICES
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2697
Practice Address - Country:US
Practice Address - Phone:973-761-9175
Practice Address - Fax:973-761-9193
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2012-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00157400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ140980XVAMedicare PIN