Provider Demographics
NPI:1609092824
Name:THEODORE, CAROL (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-0306
Mailing Address - Country:US
Mailing Address - Phone:914-276-0880
Mailing Address - Fax:914-276-0883
Practice Address - Street 1:COLONIAL COURT
Practice Address - Street 2:374 ROUTE 116
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589
Practice Address - Country:US
Practice Address - Phone:914-276-0880
Practice Address - Fax:914-276-0883
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ29525Medicare UPIN
NY0699G1Medicare ID - Type Unspecified