Provider Demographics
NPI:1275358525
Name:DECASTRO, KERRIE LYNN (CNM)
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:LYNN
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19509 E WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-6229
Mailing Address - Country:US
Mailing Address - Phone:623-237-1534
Mailing Address - Fax:
Practice Address - Street 1:580 N CAMINO MERCADO STE 8
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5757
Practice Address - Country:US
Practice Address - Phone:520-836-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ315170367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife