Provider Demographics
NPI:1013330240
Name:CHAMPION, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CHAMPION
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 1:1656 E 2ND ST
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 E 2ND ST
Practice Address - Street 2:APT 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-6920
Practice Address - Country:US
Practice Address - Phone:917-450-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY620481-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse