Provider Demographics
NPI:1952563876
Name:COSTELLO, JOAN S (PNP)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:S
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-1882
Mailing Address - Country:US
Mailing Address - Phone:972-932-1319
Mailing Address - Fax:
Practice Address - Street 1:1011 W GROVE ST
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142
Practice Address - Country:US
Practice Address - Phone:972-932-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO070459363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1952563876Medicaid
ILENROLLEDMedicaid