| Doctor Name: | MRS. KACIE JO COSTELLO |
| NPI Number: | 1841461373 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PA |
| License Number: | TL1295 |
| Business Practice Address: | 7666 Charlotte Hwy Suite 120 Indian Land, SC - 297077000 |
| Business Phone Number: | 8034318220 |
| Business Fax Number: | 8034318221 |
| Mailing Address: | Po Box 60099, CHARLOTTE |
| State: | NC |
| Postal Code: | 282600099 |
| Phone Number: | 8034318220 |
| Fax Number: | 8034318221 |
| NPI Enumeration Date: | 03/12/2008 |
| NPI Last Update Date: | 08/13/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | TL1295 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | SC |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |