Provider Demographics
NPI:1780845362
Name:COSTELLO, MERISSA L (NP)
Entity Type:Individual
Prefix:
First Name:MERISSA
Middle Name:L
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:1115 BOULDERS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:804-560-5595
Practice Address - Fax:804-590-9029
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024167442363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
12337630OtherCAQH