Provider Demographics
NPI:1962712596
Name:DECASTEELE, RUSSELL R (LPN)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:R
Last Name:DECASTEELE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:
Other - Last Name:RAYMUNDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1350 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4009
Mailing Address - Country:US
Mailing Address - Phone:631-968-6387
Mailing Address - Fax:
Practice Address - Street 1:1350 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4009
Practice Address - Country:US
Practice Address - Phone:631-968-6387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-17
Last Update Date:2010-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303043-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse