Provider Demographics
NPI:1447966262
Name:COSTLOW, MICHELLE LYN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN
Last Name:COSTLOW
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 UNIVERSITY DR E # 240
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3475
Mailing Address - Country:US
Mailing Address - Phone:903-288-7425
Mailing Address - Fax:
Practice Address - Street 1:3201 UNIVERSITY DR E # 240
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3475
Practice Address - Country:US
Practice Address - Phone:888-360-7587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099356363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health