Provider Demographics
NPI:1205830817
Name:CARR, MARY ANN (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:CARR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:ALSEA
Mailing Address - State:OR
Mailing Address - Zip Code:97324-0129
Mailing Address - Country:US
Mailing Address - Phone:541-487-7364
Mailing Address - Fax:541-487-4076
Practice Address - Street 1:435 E. ALDER
Practice Address - Street 2:
Practice Address - City:ALSEA
Practice Address - State:OR
Practice Address - Zip Code:97324-0229
Practice Address - Country:US
Practice Address - Phone:541-487-7116
Practice Address - Fax:541-487-4076
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081000957 N1 FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS92732Medicare UPIN