Healthcare Provider Details

I. General information

NPI: 1124096938
Provider Name (Legal Business Name): JOY L COSTELLO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17347 PIPA RD
PLEASANT CITY OH
43772-9668
US

IV. Provider business mailing address

17613 EASTON RD
SALESVILLE OH
43778-9878
US

V. Phone/Fax

Practice location:
  • Phone: 740-685-0854
  • Fax:
Mailing address:
  • Phone: 740-489-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-111149
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: