Basic Information
| Provider Information | |||||||||
| NPI: | 1235641994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | CLAIR | ||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11 EAST ST | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074534708 | ||||||||
| FaxNumber: | 2074536250 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 EAST ST | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074534708 | ||||||||
| FaxNumber: | 2074536250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2017 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN38869 | ME | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 010491217 | 01 | ME | MAINE | OTHER |