MEDICARE: CARL ANDREW BALLARD FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	904235	MS

General Provider Information

NPI Number	:	1386243574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL ANDREW BALLARD FNP-C

Provider Business Mailing Address
First Line	:	2635 JOHNSON BOTTOM RD
Second Line	:
City	:	DETROIT
State	:	AL
Zip	:	35552-2731
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2635 JOHNSON BOTTOM RD
Second Line	:
City	:	DETROIT
State	:	AL
Zip	:	35552-2731
Country	:	US
Telephone Number	:	205-495-0545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2020
Last Update Date	:	10/20/2020

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