Provider Demographics
NPI:1346625142
Name:CARROLL, REBECCA NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:NICOLE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:NICOLE
Other - Last Name:GRISCOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3795 OCCONECHEE TRL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-4332
Mailing Address - Country:US
Mailing Address - Phone:423-255-9698
Mailing Address - Fax:
Practice Address - Street 1:3795 OCCONECHEE TRL
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-4332
Practice Address - Country:US
Practice Address - Phone:423-255-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20483367500000X
TN153484163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse