Provider Demographics
NPI:1780055491
Name:COSTELLO, FABIOLA LUCIA (FNP - BC)
Entity type:Individual
Prefix:MRS
First Name:FABIOLA
Middle Name:LUCIA
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:FNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 CONNECTICUT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1645
Mailing Address - Country:US
Mailing Address - Phone:240-290-1041
Mailing Address - Fax:240-290-1045
Practice Address - Street 1:10901 CONNECTICUT AVE STE 100
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1645
Practice Address - Country:US
Practice Address - Phone:240-290-1041
Practice Address - Fax:240-290-1045
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD602602800Medicaid