=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245972181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE CARLSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2022
-----------------------------------------------------
Last Update Date | 04/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 SE JETTY AVE STE C
-----------------------------------------------------
City | LINCOLN CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97367-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-614-0482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2D MANOR DR
-----------------------------------------------------
City | HOOKSETT
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03106-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-301-8302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 076986-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------