Provider Demographics
NPI:1396987814
Name:DECASTRO, MICHELE JEAN (CRNP)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:JEAN
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:GIBBON 8100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-9207
Mailing Address - Fax:215-503-6134
Practice Address - Street 1:1020 SANSOM ST
Practice Address - Street 2:SUITE 239
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5002
Practice Address - Country:US
Practice Address - Phone:215-955-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010197363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102645043Medicaid
PA102645043Medicaid