Healthcare Provider Details

I. General information

NPI: 1659579704
Provider Name (Legal Business Name): CONNIE MARIE CARTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BROADWAY SUITE 1300
SACRAMENTO CA
95820-1527
US

IV. Provider business mailing address

4600 BROADWAY SUITE 1300
SACRAMENTO CA
95820-1527
US

V. Phone/Fax

Practice location:
  • Phone: 916-874-5674
  • Fax: 916-874-5489
Mailing address:
  • Phone: 916-874-5674
  • Fax: 916-874-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number467689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: