Provider Demographics
NPI:1750536561
Name:QUINTYNE, CORAL ELISE (LPN)
Entity type:Individual
Prefix:MISS
First Name:CORAL
Middle Name:ELISE
Last Name:QUINTYNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-4189
Mailing Address - Country:US
Mailing Address - Phone:347-350-3996
Mailing Address - Fax:
Practice Address - Street 1:3240 201ST ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1016
Practice Address - Country:US
Practice Address - Phone:718-428-6179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00293012164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112689787Medicaid