Provider Demographics
NPI:1447258314
Name:COSTELLO-WELLS, BRENDA LEE (CNS APRN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:COSTELLO-WELLS
Suffix:
Gender:F
Credentials:CNS APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:1500 N RITTER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3027
Practice Address - Country:US
Practice Address - Phone:317-355-2560
Practice Address - Fax:317-355-2418
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000059A364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530Medicaid
IN200223310Medicaid
IN150074Medicare PIN
IN200223310Medicaid
IN945920YMedicare PIN