Provider Demographics
NPI:1104053420
Name:COSTELLO, DAVID (CRNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12825 HANOVER DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-2612
Mailing Address - Country:US
Mailing Address - Phone:205-470-3721
Mailing Address - Fax:
Practice Address - Street 1:4300 15TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2524
Practice Address - Country:US
Practice Address - Phone:228-864-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-064521363LF0000X
MS904287363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily