Healthcare Provider Details

I. General information

NPI: 1972636116
Provider Name (Legal Business Name): CARNINA L AQUINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 W 71ST ST SUITE 201
INDIANAPOLIS IN
46278-2711
US

IV. Provider business mailing address

5980 W 71ST ST SUITE 201
INDIANAPOLIS IN
46278-2711
US

V. Phone/Fax

Practice location:
  • Phone: 317-388-0800
  • Fax: 317-388-0805
Mailing address:
  • Phone: 317-388-0800
  • Fax: 317-388-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number40QA01227200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: