MEDICARE: MARY C CARPENTER LVN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	166212	TX

General Provider Information

NPI Number	:	1023738267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY C CARPENTER LVN

Provider Business Mailing Address
First Line	:	6108 BALCONY DR APT 914
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4167
Country	:	US
Telephone Number	:	817-879-2163
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 HEMPHILL ST STE A
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-3105
Country	:	US
Telephone Number	:	817-334-0111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/29/2022

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