Provider Demographics
NPI:1548426414
Name:COSTELLO, MARY A (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W CAMINO REAL # 255
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5942
Mailing Address - Country:US
Mailing Address - Phone:704-252-1579
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST STE M404
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201508795NP-PP363LA2200X
COC-APN.0001649-C-NP363LA2200X
NC5004075363LA2200X
WI100193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004305Medicaid
SCNP1325Medicaid
WI100223521Medicaid