Provider Demographics
NPI:1801951777
Name:COSTELLO, SUSAN (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16929 FRANCES ST
Mailing Address - Street 2:STE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-4684
Mailing Address - Country:US
Mailing Address - Phone:402-717-4377
Mailing Address - Fax:
Practice Address - Street 1:7070 SPRING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3519
Practice Address - Country:US
Practice Address - Phone:402-898-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110734363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025353100Medicaid
279682Medicare ID - Type Unspecified