Basic Information
Provider Information | |||||||||
NPI: | 1215906714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELDRIDGE | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TERRELL | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | S | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9250 N 3RD ST | ||||||||
Address2: | SUITE 4010 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850202437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026333848 | ||||||||
FaxNumber: | 6026333841 | ||||||||
Practice Location | |||||||||
Address1: | 13555 W MCDOWELL RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GOODYEAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 853952624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239354700 | ||||||||
FaxNumber: | 6239354707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2006 | ||||||||
LastUpdateDate: | 04/23/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN054223 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP0670 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.