Provider Demographics
NPI:1376884775
Name:DECASTRO, MILDRED (NP)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:DECASTRO
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 1:101 W CENTRAL AVE
Mailing Address - Street 2:#249
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-7515
Mailing Address - Country:US
Mailing Address - Phone:714-273-1453
Mailing Address - Fax:714-439-1453
Practice Address - Street 1:101 W CENTRAL AVE
Practice Address - Street 2:#249
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-7515
Practice Address - Country:US
Practice Address - Phone:714-273-1453
Practice Address - Fax:714-439-1453
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-09
Last Update Date:2013-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP11295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily