Provider Demographics
NPI:1750580171
Name:CARROLL, MONIQUE RENEE (RN)
Entity type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:RENEE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W CLEARWATER RD
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6440
Mailing Address - Country:US
Mailing Address - Phone:631-225-5262
Mailing Address - Fax:
Practice Address - Street 1:111 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1052
Practice Address - Country:US
Practice Address - Phone:631-225-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY486990163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02141500Medicaid