Provider Demographics
NPI:1124403639
Name:PAULSON, CHIVONE S (NP)
Entity Type:Individual
Prefix:
First Name:CHIVONE
Middle Name:S
Last Name:PAULSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8802 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1609
Practice Address - Country:US
Practice Address - Phone:718-696-9489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-26
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402676363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health