Provider Demographics
NPI:1619789138
Name:COSTELLO, JAMES K
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:K
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:NE
Mailing Address - Zip Code:69352-5702
Mailing Address - Country:US
Mailing Address - Phone:308-737-1178
Mailing Address - Fax:
Practice Address - Street 1:411 N PARK ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:NE
Practice Address - Zip Code:69352-5702
Practice Address - Country:US
Practice Address - Phone:308-737-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26592264372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider