Healthcare Provider Details

I. General information

NPI: 1518915578
Provider Name (Legal Business Name): CAROLYN LACOURSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7866 HIDALE DR
PINCKNEY MI
48169-9239
US

IV. Provider business mailing address

PO BOX 690
HAMBURG MI
48139-0690
US

V. Phone/Fax

Practice location:
  • Phone: 810-824-8995
  • Fax:
Mailing address:
  • Phone: 810-824-8995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4704151640
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: