Provider Demographics
NPI:1720642002
Name:DECARLO, JUSTINE MARIE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARIE
Last Name:DECARLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 PERRY
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:TX
Mailing Address - Zip Code:76706-5308
Mailing Address - Country:US
Mailing Address - Phone:254-652-5875
Mailing Address - Fax:
Practice Address - Street 1:529 PERRY
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:TX
Practice Address - Zip Code:76706-5308
Practice Address - Country:US
Practice Address - Phone:254-652-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345680164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse