Provider Demographics
NPI:1174354625
Name:CARPENTER, JACQUELINE ROSE (LPN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ROSE
Other - Last Name:GLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:425 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1775
Mailing Address - Country:US
Mailing Address - Phone:607-797-0680
Mailing Address - Fax:
Practice Address - Street 1:425 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1775
Practice Address - Country:US
Practice Address - Phone:607-797-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339342164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse