Healthcare Provider Details

I. General information

NPI: 1851302996
Provider Name (Legal Business Name): RUSSELL V. K. CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 HIGHWAY 190
MANDEVILLE LA
70471-3298
US

IV. Provider business mailing address

PO BOX 772 MINUTECLINIC CREDENTIALING
WOONSOCKET RI
02895-0784
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-8106
  • Fax:
Mailing address:
  • Phone: 401-770-1669
  • Fax: 401-652-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04417
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: