Provider Demographics
NPI:1699385831
Name:CARBUCCIA, KOREN
Entity Type:Individual
Prefix:
First Name:KOREN
Middle Name:
Last Name:CARBUCCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2104
Mailing Address - Country:US
Mailing Address - Phone:401-290-8076
Mailing Address - Fax:
Practice Address - Street 1:25 MAPLE ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2104
Practice Address - Country:US
Practice Address - Phone:401-290-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI200800175T00000X
374J00000X
200800172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
No374J00000XNursing Service Related ProvidersDoula