MEDICARE: MRS. LIBBY A COSTELLO GARD FNP

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	163WP2201X	Ambulatory Care Registered Nurse	099007632RN	OR
2	363LF0000X	Family Nurse Practitioner	200850014NP	OR
3	363LF0000X	Family Nurse Practitioner	NUR-APRN-LIC-126782	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326239195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LIBBY A COSTELLO GARD FNP

Provider Business Mailing Address
First Line	:	500 W BROADWAY ST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-4008
Country	:	US
Telephone Number	:	406-327-1918
Fax Number	:	406-549-2246

Provider Business Practice Location Address
First Line	:	1211 S RESERVE ST STE 101
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-3103
Country	:	US
Telephone Number	:	406-327-3057
Fax Number	:	406-327-3231

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

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	05/10/2021

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