Healthcare Provider Details

I. General information

NPI: 1083042691
Provider Name (Legal Business Name): CAROL DOUGLASS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SEARS RD
GOSHEN MA
01032-9607
US

IV. Provider business mailing address

106 SEARS RD
GOSHEN MA
01032-9607
US

V. Phone/Fax

Practice location:
  • Phone: 413-695-9436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259384
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: