Provider Demographics
NPI:1093226763
Name:CARROLL, KATHRYN CONNER (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CONNER
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 LINDEN PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1806
Mailing Address - Country:US
Mailing Address - Phone:601-212-8455
Mailing Address - Fax:
Practice Address - Street 1:17280 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-6614
Practice Address - Country:US
Practice Address - Phone:662-834-1857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily