Healthcare Provider Details

I. General information

NPI: 1417990177
Provider Name (Legal Business Name): CAROLYN WECKS BARTLETT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8594 CRATER LAKE HWY SOUTHERN OREGON REHAB CENTERS AND CLINICS
WHITE CITY OR
97503
US

IV. Provider business mailing address

3119 CENTURION CIR
MEDFORD OR
97504-8363
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number000029126N3
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: