Provider Demographics
NPI:1194403600
Name:COSTELLO, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44 TANNERY LN
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-8365
Mailing Address - Country:US
Mailing Address - Phone:207-233-6708
Mailing Address - Fax:
Practice Address - Street 1:211 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6117
Practice Address - Country:US
Practice Address - Phone:207-877-3450
Practice Address - Fax:207-872-7910
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant