Provider Demographics
NPI:1528180296
Name:MCCONVILLE, CAROLYN (LPN)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MCCONVILLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2A ROE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4320
Mailing Address - Country:US
Mailing Address - Phone:631-642-7758
Mailing Address - Fax:
Practice Address - Street 1:2A ROE AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-4320
Practice Address - Country:US
Practice Address - Phone:631-642-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236925164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse