MEDICARE: CORAL COLON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	6NR25489700	NJ
2	163W00000X	Registered Nurse	6NR25489700	NJ

General Provider Information

NPI Number	:	1033970942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORAL COLON RN

Provider Business Mailing Address
First Line	:	190 CALDWELL AVE
Second Line	:
City	:	PATERSON
State	:	NJ
Zip	:	07501-2514
Country	:	US
Telephone Number	:	862-367-3153
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 PASSAIC AVE
Second Line	:
City	:	FAIRFIELD
State	:	NJ
Zip	:	07004-3521
Country	:	US
Telephone Number	:	862-367-3153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2024
Last Update Date	:	02/06/2024

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