Provider Demographics
NPI:1053479691
Name:CARPENTER, CARRIE MAE
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:MAE
Last Name:CARPENTER
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 1:854 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-2030
Mailing Address - Country:US
Mailing Address - Phone:440-864-4025
Mailing Address - Fax:
Practice Address - Street 1:371 LEAR RD
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2095
Practice Address - Country:US
Practice Address - Phone:440-225-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2087281Medicaid