Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 009023 | NY |
NPI | 1124589346 |
---|---|
Provider Name | Carline Marcellus |
First Address | Hewlett, NY 11557-1200 |
Second Address | Hewlett, NY 11557-1200 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2019 |
Last Update Date | 29/03/2019 |