Provider Demographics
NPI:1912109356
Name:WELLS, CARLOS JOHN (LPN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:JOHN
Last Name:WELLS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167-19 142 AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434
Mailing Address - Country:US
Mailing Address - Phone:718-316-7945
Mailing Address - Fax:
Practice Address - Street 1:9 UNION STREET
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575
Practice Address - Country:US
Practice Address - Phone:516-379-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267953164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02415024Medicaid