Provider Demographics
NPI:1538550173
Name:COSTELLO, BURTON (RN)
Entity type:Individual
Prefix:
First Name:BURTON
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8107 KERRY DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-8127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8107 KERRY DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8127
Practice Address - Country:US
Practice Address - Phone:901-299-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000197404163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse