=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093711764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANNE CARTER C.N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2005
-----------------------------------------------------
Last Update Date | 01/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 DEGRANDPRE WAY
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-6449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-563-3260
-----------------------------------------------------
Fax | 518-561-2877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 DEGRANDPRE WAY
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-6449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-563-3260
-----------------------------------------------------
Fax | 518-561-2877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | F300505
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------