Healthcare Provider Details

I. General information

NPI: 1942146147
Provider Name (Legal Business Name): BRYANNA L COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAINT JOHNS CT.
OSAGE WV
26543
US

IV. Provider business mailing address

219 BERTHA HILL RD
MAIDSVILLE WV
26541-8095
US

V. Phone/Fax

Practice location:
  • Phone: 307-276-0150
  • Fax:
Mailing address:
  • Phone: 304-282-3948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: