Provider Demographics
NPI:1235160557
Name:CARLSON, ALICE L (CNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0189
Mailing Address - Country:US
Mailing Address - Phone:812-801-0832
Mailing Address - Fax:812-801-0759
Practice Address - Street 1:1373 E STATE ROAD 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-7328
Practice Address - Country:US
Practice Address - Phone:812-801-0832
Practice Address - Fax:812-801-0759
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200161100AMedicaid
7500319OtherAETNA
500007922OtherMEDICARE RAILROAD
IN000000042220OtherANTHEM BCBS
IN412800EMedicare PIN
500007922OtherMEDICARE RAILROAD