Healthcare Provider Details

I. General information

NPI: 1336146539
Provider Name (Legal Business Name): CAROLYN MONTAQUE C.R.N.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

5645 MAIN ST
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 917-650-1275
  • Fax:
Mailing address:
  • Phone: 917-650-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number501480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: