Healthcare Provider Details

I. General information

NPI: 1407825961
Provider Name (Legal Business Name): CORETTA N WHARTON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2057
US

IV. Provider business mailing address

1150 E 83RD ST
BROOKLYN NY
11236-4704
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-4408
  • Fax:
Mailing address:
  • Phone: 917-715-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number410115-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: