Provider Demographics
NPI:1457419640
Name:COSTELLO, DOLORES (NP)
Entity Type:Individual
Prefix:DR
First Name:DOLORES
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 BROADWAY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1412
Mailing Address - Country:US
Mailing Address - Phone:212-315-0144
Mailing Address - Fax:212-315-0196
Practice Address - Street 1:1111 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-4007
Practice Address - Fax:212-315-0196
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430255164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY430255OtherLICENSE