Provider Demographics
NPI:1932258142
Name:COSTELLO, MARY JO (RD)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 NEWBURN DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15216-1213
Mailing Address - Country:US
Mailing Address - Phone:412-310-0720
Mailing Address - Fax:717-616-9251
Practice Address - Street 1:269 NEWBURN DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15216-1213
Practice Address - Country:US
Practice Address - Phone:412-310-0720
Practice Address - Fax:717-616-9251
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002628133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA630384OtherAMER DIETETIC ASSOC