1285286419 NPI number — DR. MYESHIA LA'TWAY CARROLL DNP

Table of content: DR. MYESHIA LA'TWAY CARROLL DNP (NPI 1285286419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285286419 NPI number — DR. MYESHIA LA'TWAY CARROLL DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
MYESHIA
Provider Middle Name:
LA'TWAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285286419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 404
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHILL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87357-0404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-445-7499
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INDIAN SERVICE RTE 140 & INDIAN SERVICE RTE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE HILL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-775-3271
Provider Business Practice Location Address Fax Number:
505-775-3633
Provider Enumeration Date:
07/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  282580 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 9270337 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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