Basic Information
| Provider Information | |||||||||
| NPI: | 1831761030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | COURTNY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7139 KAREN RAE CT | ||||||||
| Address2: | |||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956103838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023274534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167811000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2021 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 95017536 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.