Provider Demographics
NPI:1083087092
Name:CARROLL, MADDISON
Entity Type:Individual
Prefix:
First Name:MADDISON
Middle Name:
Last Name:CARROLL
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 1:3040 N CAMBAY CT
Mailing Address - Street 2:A
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3040 N CAMBAY CT
Practice Address - Street 2:A
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-1213
Practice Address - Country:US
Practice Address - Phone:661-319-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA151143227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered