MEDICARE: RONELL JEAN CARLSON FNP

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	363LF0000X	Family Nurse Practitioner	532880	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245273325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONELL JEAN CARLSON FNP

Provider Business Mailing Address
First Line	:	PO BOX 13276
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79768-3276
Country	:	US
Telephone Number	:	432-631-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4222 WENDOVER AVE
Second Line	:	SUITE 600
City	:	ODESSA
State	:	TX
Zip	:	79762-5945
Country	:	US
Telephone Number	:	432-552-5656
Fax Number	:	432-552-0992

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	10/03/2008

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