Provider Demographics
NPI:1376941799
Name:MASCHO, CAROLYN (ARNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MASCHO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6004
Mailing Address - Fax:
Practice Address - Street 1:1824 KING ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4735
Practice Address - Country:US
Practice Address - Phone:904-388-1820
Practice Address - Fax:904-388-1827
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267111363L00000X
FLARNP9421537363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016811800Medicaid
MI4704267111OtherMICHIGAN STATE LICENSE
MI4704267111OtherMICHIGAN STATE LICENSE