Provider Demographics
NPI:1972500189
Name:MOUNTCSTLE, KEITHA K (RN, EDD, CNS, NNP)
Entity Type:Individual
Prefix:DR
First Name:KEITHA
Middle Name:K
Last Name:MOUNTCSTLE
Suffix:
Gender:F
Credentials:RN, EDD, CNS, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W DECATUR AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-7124
Mailing Address - Country:US
Mailing Address - Phone:559-322-0868
Mailing Address - Fax:559-278-6360
Practice Address - Street 1:205 W DECATUR AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-7124
Practice Address - Country:US
Practice Address - Phone:559-322-0868
Practice Address - Fax:559-278-6360
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10646363LN0000X
CA708364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Not Answered364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal