Basic Information
| Provider Information | |||||||||
| NPI: | 1992234942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORIOLAN | ||||||||
| FirstName: | ARDOUIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 CLAREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117044014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165679626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117295750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313924357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 641751 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 341841 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 403554 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.