Provider Demographics
NPI:1083042691
Name:DOUGLASS, CAROL (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SEARS RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:MA
Mailing Address - Zip Code:01032-9607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 SEARS RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:MA
Practice Address - Zip Code:01032-9607
Practice Address - Country:US
Practice Address - Phone:413-695-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN259384163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse