Provider Demographics
NPI:1588475685
Name:GREEN, CARINE CORTRELL
Entity type:Individual
Prefix:
First Name:CARINE
Middle Name:CORTRELL
Last Name:GREEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 COUNTRY GREENS DR
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1033
Mailing Address - Country:US
Mailing Address - Phone:929-339-8963
Mailing Address - Fax:
Practice Address - Street 1:4238 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6016
Practice Address - Country:US
Practice Address - Phone:631-690-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349350164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse