Provider Demographics
NPI:1780965483
Name:COSTELLO, CYNTHIA L (LPN)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1433
Mailing Address - Country:US
Mailing Address - Phone:585-593-3218
Mailing Address - Fax:585-593-3336
Practice Address - Street 1:2129 STATE ROUTE 19
Practice Address - Street 2:PARK 2 LOT 49
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-9420
Practice Address - Country:US
Practice Address - Phone:585-808-4740
Practice Address - Fax:585-593-3336
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175219-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse