Provider Demographics
NPI:1770334757
Name:COSTELLO, NICOLE LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:25109 W GAMBIT TRL
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-9840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15521 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3437
Practice Address - Country:US
Practice Address - Phone:623-465-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ312978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily