Provider Demographics
NPI:1376674010
Name:CARROLL, KATHLEEN KELLY (MS, MA, APRN-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:KELLY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MS, MA, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 WESTMONT DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4555
Mailing Address - Country:US
Mailing Address - Phone:910-484-4061
Mailing Address - Fax:910-485-4069
Practice Address - Street 1:805 WESTMONT DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-4555
Practice Address - Country:US
Practice Address - Phone:910-484-4061
Practice Address - Fax:910-485-4069
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6455101YP2500X
NC200401185363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6113055Medicaid