Basic Information
| Provider Information | |||||||||
| NPI: | 1245750744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHATTERTON | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARKS | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 ATLANTIC AVE APT B318 | ||||||||
| Address2: | |||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117352779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2245583052 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313763000 | ||||||||
| FaxNumber: | 6313763420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.