Provider Demographics
NPI:1689993263
Name:COSTELLO, DESIREE PORTER
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:PORTER
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DESIREE
Other - Middle Name:TIFFANY
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2943 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1831
Mailing Address - Country:US
Mailing Address - Phone:315-412-1982
Mailing Address - Fax:
Practice Address - Street 1:2943 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1831
Practice Address - Country:US
Practice Address - Phone:315-412-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-22
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula