MEDICARE: CARRIE MECKLE FNP

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	R31367	ND

General Provider Information

NPI Number	:	1558799015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE MECKLE FNP

Provider Business Mailing Address
First Line	:	10 N RIVER ROAD
Second Line	:
City	:	FORT YATES
State	:	ND
Zip	:	58538
Country	:	US
Telephone Number	:	701-854-8347
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 NORTH RIVER ROAD
Second Line	:
City	:	FT YATES
State	:	ND
Zip	:	58538
Country	:	US
Telephone Number	:	701-854-8347
Fax Number	:

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

Provider Enumeration Date	:	10/21/2013
Last Update Date	:	06/02/2014

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