Healthcare Provider Details

I. General information

NPI: 1780048561
Provider Name (Legal Business Name): COLLEEN COSTELLO LEE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN COSTELLO

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4511
  • Fax: 219-836-4082
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009869A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-014187
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014187
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009869A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: