Healthcare Provider Details

I. General information

NPI: 1396084471
Provider Name (Legal Business Name): CORETTA WALSH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 08/27/2026
Certification Date:
Deactivation Date: 02/28/2025
Reactivation Date: 08/27/2026

III. Provider practice location address

175 ARDSLEY LOOP 19E
BROOKLYN NY
11239-1314
US

IV. Provider business mailing address

175 ARDSLEY LOOP 19E
BROOKLYN NY
11239-1314
US

V. Phone/Fax

Practice location:
  • Phone: 917-376-6638
  • Fax:
Mailing address:
  • Phone: 917-376-6638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number311135
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number26NP06904100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: