Provider Demographics
NPI:1427892082
Name:COSTELLO, KRISTIAN
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E 6TH ST APT 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-8240
Mailing Address - Country:US
Mailing Address - Phone:480-848-1909
Mailing Address - Fax:
Practice Address - Street 1:218 E 6TH ST APT 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8240
Practice Address - Country:US
Practice Address - Phone:480-848-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY899820163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse