Provider Demographics
NPI:1518729854
Name:WALSH, CAROLINE CLANCY
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CLANCY
Last Name:WALSH
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 1:620 W BOSTON POST RD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-3462
Mailing Address - Country:US
Mailing Address - Phone:774-217-3460
Mailing Address - Fax:
Practice Address - Street 1:1305 YORK AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:646-962-5558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353028-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily