Healthcare Provider Details

I. General information

NPI: 1528692209
Provider Name (Legal Business Name): COLETTE DWYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11223 203RD ST
SAINT ALBANS NY
11412-2209
US

IV. Provider business mailing address

11223 203RD ST
SAINT ALBANS NY
11412-2209
US

V. Phone/Fax

Practice location:
  • Phone: 555-305-3325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number642768
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: