Provider Demographics
NPI:1124765961
Name:COSTELLO, KERI (DOM)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BURTON ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2021
Mailing Address - Country:US
Mailing Address - Phone:631-972-5006
Mailing Address - Fax:
Practice Address - Street 1:295 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-2016
Practice Address - Country:US
Practice Address - Phone:401-200-8593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI317171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist