Provider Demographics
NPI:1013265206
Name:CARLESS, ALTHEA (WHNP)
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:CARLESS
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 FARRAGUT RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-1537
Mailing Address - Country:US
Mailing Address - Phone:718-253-9355
Mailing Address - Fax:718-434-0712
Practice Address - Street 1:3007 FARRAGUT RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1537
Practice Address - Country:US
Practice Address - Phone:718-253-9355
Practice Address - Fax:718-434-0712
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420969-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04333744Medicaid