Provider Demographics
NPI:1922469402
Name:COSTELLO, KRISTINE M (ANP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-463-7800
Mailing Address - Fax:618-467-0073
Practice Address - Street 1:5520 GODFREY RD STE B
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2741
Practice Address - Country:US
Practice Address - Phone:618-463-7800
Practice Address - Fax:618-467-0073
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016000994363LA2200X
IL209013674363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health