Provider Demographics
NPI:1740393818
Name:COSTELLO, CYNTHIA M (CPNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 KNIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2725
Mailing Address - Country:US
Mailing Address - Phone:818-790-1309
Mailing Address - Fax:
Practice Address - Street 1:403 WEST ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2629
Practice Address - Country:US
Practice Address - Phone:213-742-1433
Practice Address - Fax:213-742-1496
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313570363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics