Basic Information
| Provider Information | |||||||||
| NPI: | 1013272616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9372779035 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9372779035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | ARNP9381412 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | COA13322NM | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0112672 | 05 | OH | MEDICAID |