Basic Information
| Provider Information | |||||||||
| NPI: | 1083697262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11889 | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245061889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 4345442316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 LANDOVER PL | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 4345442316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 03/06/2009 | ||||||||
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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 | 363L00000X | 0017000378 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 013531C83 | 01 | MEDICARE PROVIDER NUMBER PRIOR TO 09/01/07 | OTHER | 014912C58 | 01 | MEDICARE INDIVIDUAL PTAN EFFECTIVE TO 09/01/07 | OTHER | C03658 | 01 | MEDICARE GROUP PTAN EFFECTIVE 09/01/07 | OTHER | 1083697262 | 05 | VA | MEDICAID | 1407936941 | 01 | CVFP SITE ID | OTHER | P00667138 | 01 | MEDICARE RAILROAD | OTHER | 1528155892 | 01 | CORPORATE NPI NUMBER | OTHER | C08183 | 01 | MEDICARE GROUP NUMBER PRIOR TO 09/01/07 | OTHER |