Provider Demographics
NPI:1164065645
Name:BALLARD, CARRIE MARIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:BALLARD
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 1:9126 ELK GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-2013
Mailing Address - Country:US
Mailing Address - Phone:916-333-0383
Mailing Address - Fax:916-244-9898
Practice Address - Street 1:9126 ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-2013
Practice Address - Country:US
Practice Address - Phone:916-333-0383
Practice Address - Fax:916-244-9898
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3447000403747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider