Healthcare Provider Details

I. General information

NPI: 1588475685
Provider Name (Legal Business Name): CARINE CORTRELL GREEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 MERRICK RD
MASSAPEQUA NY
11758-6016
US

IV. Provider business mailing address

33 COUNTRY GREENS DR
HOLTSVILLE NY
11742-1033
US

V. Phone/Fax

Practice location:
  • Phone: 631-690-5155
  • Fax:
Mailing address:
  • Phone: 929-339-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number349350
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: