Provider Demographics
NPI:1124574603
Name:BECERRA, CAROL G (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:G
Last Name:BECERRA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:MARTINEZ-BECERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8 RADCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-6100
Mailing Address - Country:US
Mailing Address - Phone:917-288-1224
Mailing Address - Fax:
Practice Address - Street 1:8 RADCLIFF LN
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-6100
Practice Address - Country:US
Practice Address - Phone:917-288-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705454-1163W00000X
FLRN9361720163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse