Basic Information
| Provider Information | |||||||||
| NPI: | 1386884252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | NANETTE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400010 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891400010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022149741 | ||||||||
| FaxNumber: | 7025434326 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107151010 | ||||||||
| FaxNumber: | 9107151026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2009 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6263 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363L00000X | APN001093 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.