Provider Demographics
NPI:1063037620
Name:CARROLL, LYNNE MARIE (RN, BSN, MSN)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:MARIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN, BSN, MSN
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:MARIE
Other - Last Name:KAUFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:44463 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:IA
Mailing Address - Zip Code:51521-2019
Mailing Address - Country:US
Mailing Address - Phone:712-249-6526
Mailing Address - Fax:
Practice Address - Street 1:1750 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3814
Practice Address - Country:US
Practice Address - Phone:712-215-6588
Practice Address - Fax:712-322-9585
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061951163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA061951Medicaid