Healthcare Provider Details

I. General information

NPI: 1366245300
Provider Name (Legal Business Name): KIMBERLEY COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1496 POWER STATION HWY
MOUNT STORM WV
26739-8689
US

IV. Provider business mailing address

1496 POWER STATION HWY
MOUNT STORM WV
26739-8689
US

V. Phone/Fax

Practice location:
  • Phone: 304-216-2945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: