Individual
JENNIFER COSTELLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGACNP
Contact information
Practice address
111 S 11TH ST, PHILADELPHIA, PA 19107-4824
(215) 955-4535
(215) 503-5939
Mailing address
5250 RIDGE AVE, PHILADELPHIA, PA 19128-3712
(570) 259-0848
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
SP019737
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
SP019737
STATE BOARD OF NURSING
PA
Enumeration date
12/17/2018
Last updated
12/17/2018
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