Provider Demographics
NPI:1043038334
Name:KOSTELLO, TRISTA (NP)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:KOSTELLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 SPRAGUES MILL CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3327
Mailing Address - Country:US
Mailing Address - Phone:636-751-4336
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8726
Practice Address - Country:US
Practice Address - Phone:314-251-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015022116163W00000X
MO2024043059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse