Provider Demographics
NPI:1235583162
Name:CARR, CHEYENNE STACY
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:STACY
Last Name:CARR
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 1:36 PELLINORE CT
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1096
Mailing Address - Country:US
Mailing Address - Phone:410-598-9638
Mailing Address - Fax:
Practice Address - Street 1:9050 IRON HORSE LN
Practice Address - Street 2:APT 138
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-2154
Practice Address - Country:US
Practice Address - Phone:410-598-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR158738367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered