MEDICARE: MRS. JOY L COSTELLO LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN-111149	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2364436	OTHER	OH	PERSONAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1124096938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOY L COSTELLO LPN

Provider Business Mailing Address
First Line	:	17613 EASTON RD
Second Line	:
City	:	SALESVILLE
State	:	OH
Zip	:	43778-9878
Country	:	US
Telephone Number	:	740-489-9248
Fax Number	:

Provider Business Practice Location Address
First Line	:	17347 PIPA RD
Second Line	:
City	:	PLEASANT CITY
State	:	OH
Zip	:	43772-9668
Country	:	US
Telephone Number	:	740-685-0854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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