Provider Demographics
NPI:1922285618
Name:FOSELLA, CORALEEN ITABLE (NP)
Entity Type:Individual
Prefix:
First Name:CORALEEN
Middle Name:ITABLE
Last Name:FOSELLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:525 E 68TH ST
Mailing Address - Street 2:BOX 308
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:646-962-5483
Mailing Address - Fax:646-962-0363
Practice Address - Street 1:1305 YORK AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:646-962-5483
Practice Address - Fax:646-962-0363
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301611363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS79153Medicare UPIN