Provider Demographics
NPI:1073703088
Name:MCCARTHY, COLLEEN DEIDRE (RN)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:DEIDRE
Last Name:MCCARTHY
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 1:120 96TH ST
Mailing Address - Street 2:#2E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7547
Mailing Address - Country:US
Mailing Address - Phone:718-680-5643
Mailing Address - Fax:
Practice Address - Street 1:120 96TH ST
Practice Address - Street 2:#2E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7547
Practice Address - Country:US
Practice Address - Phone:718-680-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505975163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01866875Medicaid