Provider Demographics
NPI:1043266711
Name:CARLSON, SUSAN RENEE (MSN, ANP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RENEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2740 N HWY 360
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-6403
Mailing Address - Country:US
Mailing Address - Phone:972-606-8300
Mailing Address - Fax:972-606-4940
Practice Address - Street 1:2740 N HWY 360
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-6403
Practice Address - Country:US
Practice Address - Phone:972-606-8300
Practice Address - Fax:972-606-4940
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX565581363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156976601Medicaid
TX156976601Medicaid
TX8A3462Medicare PIN