Healthcare Provider Details

I. General information

NPI: 1457956286
Provider Name (Legal Business Name): MARY CLAIRE CARBONELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 1ST ST
GRANDFIELD OK
73546-9236
US

IV. Provider business mailing address

2450 HOLCOMBE BLVD STE 2200
HOUSTON TX
77021-2039
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-6688
  • Fax:
Mailing address:
  • Phone: 405-832-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0100066
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: