Provider Demographics
NPI:1083257372
Name:CARROLL, CLARIZZA (APRN, CNS)
Entity Type:Individual
Prefix:
First Name:CLARIZZA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:APRN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12582 CLEM DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OK
Mailing Address - Zip Code:73448-2165
Mailing Address - Country:US
Mailing Address - Phone:580-276-3245
Mailing Address - Fax:
Practice Address - Street 1:304 FAIRLANE AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-6861
Practice Address - Country:US
Practice Address - Phone:580-622-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61627364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health