Provider Demographics
NPI:1255571170
Name:WALCOTT, DEBRA ANNMARGO
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANNMARGO
Last Name:WALCOTT
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 1:282 CHAUNCEY ST
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-2307
Mailing Address - Country:US
Mailing Address - Phone:917-362-8789
Mailing Address - Fax:
Practice Address - Street 1:9715 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2250
Practice Address - Country:US
Practice Address - Phone:718-459-5592
Practice Address - Fax:718-459-6047
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse