Provider Demographics
NPI:1992211577
Name:WILLIAMS, CARLA LUNA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:LUNA
Last Name:WILLIAMS
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 1:20 GENOA ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-1728
Mailing Address - Country:US
Mailing Address - Phone:631-943-3352
Mailing Address - Fax:
Practice Address - Street 1:248 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2505
Practice Address - Country:US
Practice Address - Phone:718-681-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402311-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid