MEDICARE: MARY KELLEY COSTELLO R.N.

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	163W00000X	Registered Nurse	RN.359661	OH

General Provider Information

NPI Number	:	1770891657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KELLEY COSTELLO R.N.

Provider Business Mailing Address
First Line	:	4084 W 56TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44144-1842
Country	:	US
Telephone Number	:	216-799-3597
Fax Number	:

Provider Business Practice Location Address
First Line	:	4084 W 56TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44144-1842
Country	:	US
Telephone Number	:	216-799-3597
Fax Number	:

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

Provider Enumeration Date	:	09/14/2010
Last Update Date	:	09/14/2010

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