Basic Information
| Provider Information | |||||||||
| NPI: | 1851350359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARBONNEAU | ||||||||
| FirstName: | M. | ||||||||
| MiddleName: | FRANCINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEENEY | ||||||||
| OtherFirstName: | M | ||||||||
| OtherMiddleName: | FRANCINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 COMMUNICATIONS WAY | ||||||||
| Address2: | MACC - REVENUE CYCLE | ||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026011866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089578664 | ||||||||
| FaxNumber: | 5089578677 | ||||||||
| Practice Location | |||||||||
| Address1: | 257 STATION AVENUE | ||||||||
| Address2: | |||||||||
| City: | SOUTH YARMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083948303 | ||||||||
| FaxNumber: | 5083986680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 363L00000X | 150717 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP1059 | 01 | MA | BCBS | OTHER |