Healthcare Provider Details

I. General information

NPI: 1750874616
Provider Name (Legal Business Name): KATIE CARROLL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 N 38TH ST UNIT C
PHILADELPHIA PA
19104-1655
US

IV. Provider business mailing address

150 BLUFF AVE
NORTH AUGUSTA SC
29841-3862
US

V. Phone/Fax

Practice location:
  • Phone: 267-322-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN594050
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: