Provider Demographics
NPI:1003850405
Name:COSTELLO, JACQUELINE R (DNP, APRN, CPNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DNP, APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 E BOOKER DAIRY RD STE B
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-9472
Mailing Address - Country:US
Mailing Address - Phone:919-938-2144
Mailing Address - Fax:
Practice Address - Street 1:1519 E BOOKER DAIRY RD STE B
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9472
Practice Address - Country:US
Practice Address - Phone:919-938-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9223611363L00000X
NC5006348363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1003850405Medicaid
NCNCF6190322Medicare PIN