Provider Demographics
NPI:1164968483
Name:MERSEREAU, CARRIE SUE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:SUE
Last Name:MERSEREAU
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:SUE
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:5757 MONCLOVA RD STE 26
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-5557
Mailing Address - Fax:419-893-5199
Practice Address - Street 1:5757 MONCLOVA RD STE 26
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-5557
Practice Address - Fax:419-893-5199
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH024233363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1164968483Medicaid
OH1164968483OtherNPI