Healthcare Provider Details

I. General information

NPI: 1124494505
Provider Name (Legal Business Name): JANET CARROLL R.N., M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N BEND DR
FORT WAYNE IN
46804-1753
US

IV. Provider business mailing address

5111 N BEND DR
FORT WAYNE IN
46804-1753
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8807
  • Fax: 260-436-2767
Mailing address:
  • Phone: 260-436-8807
  • Fax: 260-436-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number28057959A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20901877
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: