Healthcare Provider Details

I. General information

NPI: 1912718107
Provider Name (Legal Business Name): CAROL THERESA RUANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 BROADHOLLOW RD STE 200
MELVILLE NY
11747-4833
US

IV. Provider business mailing address

265 BROADHOLLOW RD STE 200
MELVILLE NY
11747-4833
US

V. Phone/Fax

Practice location:
  • Phone: 631-553-8347
  • Fax:
Mailing address:
  • Phone: 631-553-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number376667-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: