Provider Demographics
NPI:1548797376
Name:COSTELLO, MACKENZIE (CRNP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:SCOFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1630 MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619-2792
Mailing Address - Country:US
Mailing Address - Phone:410-604-6560
Mailing Address - Fax:410-643-5789
Practice Address - Street 1:1630 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2792
Practice Address - Country:US
Practice Address - Phone:410-604-6560
Practice Address - Fax:410-643-5789
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1033652163W00000X
MDR227450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse