Basic Information
| Provider Information | |||||||||
| NPI: | 1770089385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | LOUISE | ||||||||
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| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | HANNAH | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 229 NORTH DR APT 2 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142162041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182294211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 955 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168296124 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.