Healthcare Provider Details

I. General information

NPI: 1366131815
Provider Name (Legal Business Name): MADELENE COSTELLO MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 GEORGETTA LN
NEWARK TX
76071-3899
US

IV. Provider business mailing address

3900 GRAPEVINE MILLS PKWY UNIT 2428
GRAPEVINE TX
76051-0929
US

V. Phone/Fax

Practice location:
  • Phone: 509-961-0271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1021688
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: