Provider Demographics
NPI:1548538119
Name:COSTELLO, ELIZABETH RUTH
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RUTH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:RUTH
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:11 WEST FIRST STREET
Mailing Address - Street 2:CORNING FREE ACADEMY
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 WEST THIRD STREET
Practice Address - Street 2:CORNING FREE ACADEMY
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830
Practice Address - Country:US
Practice Address - Phone:607-654-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY386533-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse