Healthcare Provider Details

I. General information

NPI: 1629218664
Provider Name (Legal Business Name): CAROLYN M SLATTERY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5610 2ND AVE
BROOKLYN NY
11220-3599
US

IV. Provider business mailing address

5610 2ND AVE
BROOKLYN NY
11220-3599
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7241
  • Fax: 718-630-6878
Mailing address:
  • Phone: 718-630-7241
  • Fax: 718-630-6878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number588044-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF001325-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: