Basic Information
Provider Information | |||||||||
NPI: | 1831390012 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANSEN | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RNC FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12 WAGON DR | ||||||||
Address2: |   | ||||||||
City: | WILBRAHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 010951678 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135991356 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 80 CONGRESS ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011043564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137320040 | ||||||||
FaxNumber: | 4137327007 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2007 | ||||||||
LastUpdateDate: | 01/27/2013 | ||||||||
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 | 126357 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 110089946A | 05 | MA |   | MEDICAID |