MEDICARE: JOHNETTA RA'SHAWN CARROLL

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	363LG0600X	Gerontology Nurse Practitioner	1-177842	AL

General Provider Information

NPI Number	:	1407708100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNETTA RA'SHAWN CARROLL

Provider Business Mailing Address
First Line	:	208 CARR CIR
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-1906
Country	:	US
Telephone Number	:	334-718-2444
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 CARR CIR
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-1906
Country	:	US
Telephone Number	:	334-718-2444
Fax Number	:

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

Provider Enumeration Date	:	02/13/2026
Last Update Date	:	02/13/2026

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