Provider Demographics
NPI:1093146979
Name:CARROLL, KATHY (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4404
Mailing Address - Country:US
Mailing Address - Phone:850-763-9744
Mailing Address - Fax:850-785-2020
Practice Address - Street 1:2306 HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4404
Practice Address - Country:US
Practice Address - Phone:850-763-9744
Practice Address - Fax:850-785-2020
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2145292364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303682100Medicaid
FL303682100Medicaid