Provider Demographics
NPI:1194889741
Name:SMALL, DOREEN MARY (RN)
Entity type:Individual
Prefix:MRS
First Name:DOREEN
Middle Name:MARY
Last Name:SMALL
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 1:306 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3507
Mailing Address - Country:US
Mailing Address - Phone:631-773-5370
Mailing Address - Fax:631-773-5369
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3507
Practice Address - Country:US
Practice Address - Phone:631-773-5370
Practice Address - Fax:631-773-5369
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271783163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR01951Medicare ID - Type UnspecifiedMEDICARE PROVIDER