Basic Information
| Provider Information | |||||||||
| NPI: | 1922295096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLUCCI | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLUCCI | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | REGISTERED NURSE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 189 WHEATLEY RD | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166261000 | ||||||||
| FaxNumber: | 5166262039 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 WHEATLEY RD | ||||||||
| Address2: | |||||||||
| City: | GLEN HEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115452641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166261000 | ||||||||
| FaxNumber: | 5166262039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4150331 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 111720254 | 01 | NY | 111720254 | OTHER |