Provider Demographics
NPI:1386884252
Name:COSTELLO, NANETTE K (CRNA)
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:K
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400010
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89140-0010
Mailing Address - Country:US
Mailing Address - Phone:702-214-9741
Mailing Address - Fax:702-543-4326
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-1010
Practice Address - Fax:910-715-1026
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6263367500000X
NVAPN001093363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVBP361ZMedicare PIN