1710527650 NPI number — CARLEE THERIOT CARROLL APRN, FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710527650 NPI number — CARLEE THERIOT CARROLL APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
CARLEE
Provider Middle Name:
THERIOT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
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:
1710527650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 122165 DEPT 2165
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75312-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
373-494-2772
Provider Business Mailing Address Fax Number:
337-494-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 OAK PARK BLVD FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-8990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
374-944-9063
Provider Business Practice Location Address Fax Number:
337-494-4936
Provider Enumeration Date:
01/08/2020

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:  210944 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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