Provider Demographics
NPI:1225516826
Name:PATRICK, CARRISA SUZETTE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CARRISA
Middle Name:SUZETTE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 W HIGHWAY 248
Mailing Address - Street 2:
Mailing Address - City:WALDRON
Mailing Address - State:AR
Mailing Address - Zip Code:72958-8639
Mailing Address - Country:US
Mailing Address - Phone:501-802-0072
Mailing Address - Fax:
Practice Address - Street 1:6108 S 31ST ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-7555
Practice Address - Country:US
Practice Address - Phone:479-242-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA005820OtherAPRN LICENSE