Provider Demographics
NPI:1326652470
Name:STANFORD, CAROLYN LEE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LEE
Last Name:STANFORD
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 1:6705 W HIGHWAY 290 STE 502
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8407
Mailing Address - Country:US
Mailing Address - Phone:512-647-9883
Mailing Address - Fax:
Practice Address - Street 1:14902 CROSSCREEK
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-8904
Practice Address - Country:US
Practice Address - Phone:512-647-9883
Practice Address - Fax:512-647-9883
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP110163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily