Provider Demographics
NPI:1376115212
Name:CARROLL, DALTON ROBERT (FNP-C)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:ROBERT
Last Name:CARROLL
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 DUMAINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6277
Mailing Address - Country:US
Mailing Address - Phone:318-751-1246
Mailing Address - Fax:
Practice Address - Street 1:8445 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-5925
Practice Address - Country:US
Practice Address - Phone:318-703-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA220441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily