Basic Information
Provider Information
NPI: 1003012352
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOOTS
FirstName: CARRIE
MiddleName: JEAN
NamePrefix:  
NameSuffix:  
Credential: N.P.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BALLER
OtherFirstName: CARRIE
OtherMiddleName: JEAN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: N.P.
OtherLastNameType: 1
Mailing Information
Address1: 11143 PARKVIEW PLAZA DR STE 100
Address2:  
City: FORT WAYNE
State: IN
PostalCode: 468451728
CountryCode: US
TelephoneNumber: 2604848830
FaxNumber: 2604831911
Practice Location
Address1: 7910 W JEFFERSON BLVD
Address2: SUITE 108
City: FORT WAYNE
State: IN
PostalCode: 46804
CountryCode: US
TelephoneNumber: 2604848830
FaxNumber: 2604831911
Other Information
ProviderEnumerationDate: 06/25/2007
LastUpdateDate: 07/10/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LA2200X71002416AINY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health

No ID Information.


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