Provider Demographics
NPI:1184968133
Name:COSTELLO, JOHNNA SUZANNE (FNP-C)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:SUZANNE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JOHNNA
Other - Middle Name:SUZANNE
Other - Last Name:WENDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9107
Practice Address - Fax:316-689-9354
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75854-011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201012490CMedicaid
003719478OtherMEDICARE