Provider Demographics
NPI:1407538309
Name:PROVIDENCE, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PROVIDENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 JORALEMON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4306
Mailing Address - Country:US
Mailing Address - Phone:718-722-6190
Mailing Address - Fax:718-722-6189
Practice Address - Street 1:191 JORALEMON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4306
Practice Address - Country:US
Practice Address - Phone:718-722-6190
Practice Address - Fax:718-722-6189
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker