Basic Information
| Provider Information | |||||||||
| NPI: | 1174267793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RRT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WATSON | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RRT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 526 EVOLVE DR | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275294693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192626088 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KENANSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283498801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102960941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2022 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | 6683 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
No ID Information.