Basic Information
| Provider Information | |||||||||
| NPI: | 1801067251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCUM | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | RUTH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 DULLES DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705063718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Practice Location | |||||||||
| Address1: | 5865 RIDEWAY CENTER PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381203812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 13353 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | A810297 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APN13353 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 141621 | TN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 00927745 | 05 | MS | MEDICAID | 4182890 | 01 | TN | TN BCBS | OTHER | 3341699 | 05 | TN | MEDICAID | 168400758 | 05 | AR | MEDICAID | 1801067251 | 01 | AR | AR BCBS | OTHER |