=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326254590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. CAROLYN ROUSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 463 COMMONWEALTH AVE
-----------------------------------------------------
City | ERLANGER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41018-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-342-0655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 17522
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-0522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-342-0655
-----------------------------------------------------
Fax | 859-342-0883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | KY 0816
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------