Healthcare Provider Details

I. General information

NPI: 1477299139
Provider Name (Legal Business Name): JAMIE NICOLE COSTELLO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GREAT CIRCLE RD FL 3
NASHVILLE TN
37228-1317
US

IV. Provider business mailing address

655 BRAWLEY SCHOOL RD STE 200
MOORESVILLE NC
28117-9601
US

V. Phone/Fax

Practice location:
  • Phone: 615-436-9060
  • Fax: 615-235-9725
Mailing address:
  • Phone: 704-696-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025184
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704393179
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP0035621
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015149B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: