Provider Demographics
NPI:1417704362
Name:COSTELLO, SUSAN MARIE (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11252 S SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3536
Mailing Address - Country:US
Mailing Address - Phone:773-946-7738
Mailing Address - Fax:
Practice Address - Street 1:4471 LAWN AVE STE 202
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1765
Practice Address - Country:US
Practice Address - Phone:708-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.0257534363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health