Healthcare Provider Details

I. General information

NPI: 1093065880
Provider Name (Legal Business Name): CAROLYN PATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 TAMARACK CT
RALEIGH NC
27612-2373
US

IV. Provider business mailing address

2308 TAMARACK CT
RALEIGH NC
27612-2373
US

V. Phone/Fax

Practice location:
  • Phone: 773-938-1181
  • Fax:
Mailing address:
  • Phone: 773-938-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3456
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: