Provider Demographics
NPI:1003012352
Name:BOOTS, CARRIE JEAN (NP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JEAN
Last Name:BOOTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JEAN
Other - Last Name:BALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6610 MUTUAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4236
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 108
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002416A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN055770SMedicare PIN