=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134764863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENEE CARLTON LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2019
-----------------------------------------------------
Last Update Date | 11/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3311 POLKVILLE RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-8682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-473-3206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3311 POLKVILLE RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-8682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-473-3206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 78815
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------