Provider Demographics
NPI:1962694182
Name:FEARBY, CAROL JEAN (LPN)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:JEAN
Last Name:FEARBY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 COOLEY MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PARKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12768-5312
Mailing Address - Country:US
Mailing Address - Phone:845-292-7985
Mailing Address - Fax:
Practice Address - Street 1:2012 COOLEY MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PARKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12768-5312
Practice Address - Country:US
Practice Address - Phone:845-292-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2007-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259050164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02514538Medicaid