Provider Demographics
NPI:1629131776
Name:GUNNERSEN, CAROL ANN (LPN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:GUNNERSEN
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 1:6890 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9677
Mailing Address - Country:US
Mailing Address - Phone:716-947-9141
Mailing Address - Fax:
Practice Address - Street 1:2250 WEHRLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7037
Practice Address - Country:US
Practice Address - Phone:716-276-2123
Practice Address - Fax:716-276-2129
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144399-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse