Basic Information
| Provider Information | |||||||||
| NPI: | 1871979229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | CARMELIA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 997 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585020997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2111 LANDMARK CIR NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197341779 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2015 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | F07151248 | NC | N | Allopathic & Osteopathic Physicians | Hospitalist | 363L00000X | R47017 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1871979229 | 05 | NC | MEDICAID |