Provider Demographics
NPI:1104331214
Name:COSTELLO, LAUREN (FNP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 28TH ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2877
Mailing Address - Country:US
Mailing Address - Phone:516-428-5155
Mailing Address - Fax:
Practice Address - Street 1:1305 YORK AVE FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:646-962-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341654-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner