Provider Demographics
NPI:1871979229
Name:CARROLL, CARMELIA RENEE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:CARMELIA
Middle Name:RENEE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:701-530-7000
Mailing Address - Fax:
Practice Address - Street 1:2111 LANDMARK CIR NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-1967
Practice Address - Country:US
Practice Address - Phone:919-734-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-08
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF07151248208M00000X
NDR47017363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1871979229Medicaid