Provider Demographics
NPI:1740408020
Name:COSTELLO, KATHLEEN M (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64227
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4227
Mailing Address - Country:US
Mailing Address - Phone:410-410-9331
Mailing Address - Fax:410-502-6736
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:PATHOLOGY BLDG - RM 625
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-614-1066
Practice Address - Fax:410-502-6736
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR069246363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400003000Medicaid
MD400003000Medicaid