Provider Demographics
NPI:1609407329
Name:CASTRO, KELLI MARIE (APRN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:HAVILAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, AGACNP-BC
Mailing Address - Street 1:2925 TYLER CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1009
Mailing Address - Country:US
Mailing Address - Phone:309-945-8218
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:309-945-8218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144847363LA2100X
IL209020949363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care