Provider Demographics
NPI:1578701686
Name:DECARLO, DEBRA (RN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:DECARLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:DETAMBLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1526 WALDEN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1526 WALDEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4985
Practice Address - Country:US
Practice Address - Phone:716-895-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 424043163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse