Healthcare Provider Details

I. General information

NPI: 1033764006
Provider Name (Legal Business Name): JEANINE MICHELLE CARNIVAL MS, RN, AGNP-C, CCRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICHOLLS ROAD STONY BROOK HOSPITA
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

101 NICHOLLS ROAD STONY BROOK HOSPITA
STONY BROOK NY
11794-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1665
  • Fax:
Mailing address:
  • Phone: 631-444-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308885
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: