Provider Demographics
NPI:1396382446
Name:CARLOUGH, CHRISTINA ROSE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ROSE
Last Name:CARLOUGH
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 1:36 BRONSON LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8725
Mailing Address - Country:US
Mailing Address - Phone:386-307-2407
Mailing Address - Fax:386-302-0289
Practice Address - Street 1:36 BRONSON LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8725
Practice Address - Country:US
Practice Address - Phone:386-307-2407
Practice Address - Fax:386-302-0289
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALF13355172V00000X
FL13355310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No172V00000XOther Service ProvidersCommunity Health Worker