Provider Demographics
NPI:1477299139
Name:COSTELLO, JAMIE NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2820 MARIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3447
Mailing Address - Country:US
Mailing Address - Phone:217-274-0787
Mailing Address - Fax:
Practice Address - Street 1:39425 GARFIELD RD STE 24
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4651
Practice Address - Country:US
Practice Address - Phone:586-649-3181
Practice Address - Fax:586-649-3182
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209025184363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner