Provider Demographics
NPI:1003379413
Name:NANCE, CARRIE LYNN
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:NANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1468
Mailing Address - Country:US
Mailing Address - Phone:317-257-2229
Mailing Address - Fax:
Practice Address - Street 1:7110 BRAXTON DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8134
Practice Address - Country:US
Practice Address - Phone:317-776-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN222Q00000XMedicaid