Provider Demographics
NPI:1093742264
Name:CARROLL, FRETH L (RN CNOR CRNFA)
Entity Type:Individual
Prefix:MS
First Name:FRETH
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN CNOR CRNFA
Other - Prefix:MS
Other - First Name:FRETH
Other - Middle Name:L
Other - Last Name:BRODIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNFA
Mailing Address - Street 1:1266 E LONE STAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610
Mailing Address - Country:US
Mailing Address - Phone:512-376-9380
Mailing Address - Fax:512-215-8485
Practice Address - Street 1:1266 E LONE STAR DR
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-4885
Practice Address - Country:US
Practice Address - Phone:512-376-9380
Practice Address - Fax:512-215-8485
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222322163W00000X, 163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149093001Medicaid
TX89N901OtherBLUE CROSS BLUE SHIELD