Provider Demographics
NPI:1871567537
Name:CASTRO, MARY ELLEN P (APRN)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:P
Last Name:CASTRO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:SUITE #263
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-5386
Mailing Address - Country:US
Mailing Address - Phone:860-679-5547
Mailing Address - Fax:860-679-5552
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:SUITE #263
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-5386
Practice Address - Country:US
Practice Address - Phone:860-679-5547
Practice Address - Fax:860-679-5552
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CTE48342163W00000X
CT001506363LA2200X, 363LG0600X, 364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004189579Medicaid
S51763Medicare UPIN
CT004189579Medicaid