Healthcare Provider Details

I. General information

NPI: 1679955736
Provider Name (Legal Business Name): ANN R COSTELLO MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N AURORA ST
ITHACA NY
14850-4345
US

IV. Provider business mailing address

217 N AURORA ST
ITHACA NY
14850-4345
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-2811
  • Fax: 607-273-1170
Mailing address:
  • Phone: 607-273-2811
  • Fax: 607-273-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF338797-1
License Number StateNY

VIII. Authorized Official

Name: DR. ANN R COSTELLO
Title or Position: OWNER
Credential: MD
Phone: 607-273-2811