Provider Demographics
NPI:1043451198
Name:CARROUCHE, CARMEN LILY (RN, CNS, PMH-NP)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LILY
Last Name:CARROUCHE
Suffix:
Gender:F
Credentials:RN, CNS, PMH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RITTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3323
Mailing Address - Country:US
Mailing Address - Phone:415-457-8182
Mailing Address - Fax:415-457-3490
Practice Address - Street 1:16 RITTER ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3323
Practice Address - Country:US
Practice Address - Phone:415-457-8182
Practice Address - Fax:415-457-3490
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510142163WP0808X
CA23466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health