Provider Demographics
NPI:1669406864
Name:BRADDOCK, CAROLYN R (NP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1401
Mailing Address - Country:US
Mailing Address - Phone:585-279-4800
Mailing Address - Fax:585-442-8319
Practice Address - Street 1:777 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1401
Practice Address - Country:US
Practice Address - Phone:585-279-4800
Practice Address - Fax:585-442-8319
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP019330028OtherBLUE CHOICE
NYNP0405OtherPREFERRED CARE
NYCC3099Medicare PIN
NYNP0405OtherPREFERRED CARE