Provider Demographics
NPI:1417085846
Name:COSTELLA, CAROLYN S (MSN APRN BC)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:S
Last Name:COSTELLA
Suffix:
Gender:F
Credentials:MSN APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 KINGS HWY S STE 2101
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2524
Mailing Address - Country:US
Mailing Address - Phone:856-208-7300
Mailing Address - Fax:856-254-0019
Practice Address - Street 1:1010 KINGS HWY S STE 2101
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2524
Practice Address - Country:US
Practice Address - Phone:856-208-7300
Practice Address - Fax:856-254-0019
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00041700363L00000X, 363LP0808X
NJ26NR10857800163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0183946Medicaid
NJ0305715Medicaid