Provider Demographics
NPI:1578034989
Name:WALCOTT, CARENA LAUREL (NP)
Entity Type:Individual
Prefix:
First Name:CARENA
Middle Name:LAUREL
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 SAINT MARKS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-4723
Mailing Address - Country:US
Mailing Address - Phone:718-825-5060
Mailing Address - Fax:
Practice Address - Street 1:11220 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1814
Practice Address - Country:US
Practice Address - Phone:718-554-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342127-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily