Healthcare Provider Details

I. General information

NPI: 1164065645
Provider Name (Legal Business Name): CARRIE MARIE BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9126 ELK GROVE BLVD
ELK GROVE CA
95624-2013
US

IV. Provider business mailing address

9126 ELK GROVE BLVD
ELK GROVE CA
95624-2013
US

V. Phone/Fax

Practice location:
  • Phone: 916-333-0383
  • Fax: 916-244-9898
Mailing address:
  • Phone: 916-333-0383
  • Fax: 916-244-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number344700040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: