Basic Information
Provider Information | |||||||||
NPI: | 1881356574 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARTER | ||||||||
FirstName: | CORETTA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1621 W PEACE ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MS | ||||||||
PostalCode: | 390469041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013912716 | ||||||||
FaxNumber: | 6013912717 | ||||||||
Practice Location | |||||||||
Address1: | 3166 S STATE HIGHWAY 161 STE 170 | ||||||||
Address2: |   | ||||||||
City: | GRAND PRAIRIE | ||||||||
State: | TX | ||||||||
PostalCode: | 750527720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726400005 | ||||||||
FaxNumber: | 2103145044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2021 | ||||||||
LastUpdateDate: | 09/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1092111 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.