Basic Information
| Provider Information | |||||||||
| NPI: | 1033764006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARNIVAL | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | MS, RN, AGNP-C, CCRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 NICHOLLS ROAD STONY BROOK HOSPITA | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 NICHOLLS ROAD STONY BROOK HOSPITA | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441665 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F308885 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.