Healthcare Provider Details

I. General information

NPI: 1861623696
Provider Name (Legal Business Name): MS. DAWNELL CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RIVIERA DR E
MASSAPEQUA NY
11758-8511
US

IV. Provider business mailing address

11 RIVIERA DR E
MASSAPEQUA NY
11758-8511
US

V. Phone/Fax

Practice location:
  • Phone: 516-799-2214
  • Fax:
Mailing address:
  • Phone: 516-799-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number381956
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number403603
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: