Provider Demographics
NPI:1700941382
Name:DECASTRO, KIM (CNP, CNM)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:CNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2120
Mailing Address - Country:US
Mailing Address - Phone:631-473-7171
Mailing Address - Fax:
Practice Address - Street 1:118 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2120
Practice Address - Country:US
Practice Address - Phone:631-473-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF360326-1363L00000X
NYF000792-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife