Provider Demographics
NPI:1497143572
Name:CASTRO, SHAUNTI
Entity Type:Individual
Prefix:
First Name:SHAUNTI
Middle Name:
Last Name:CASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 N KEDZIE AVE
Mailing Address - Street 2:UNIT 1R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6723
Mailing Address - Country:US
Mailing Address - Phone:773-988-5441
Mailing Address - Fax:
Practice Address - Street 1:520 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1022
Practice Address - Country:US
Practice Address - Phone:708-383-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-25
Last Update Date:2014-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered