Provider Demographics
NPI:1396830485
Name:CARROLL, LAURA S (CFNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DRIVE
Mailing Address - Street 2:SUITE 1157
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-362-6900
Mailing Address - Fax:601-362-6111
Practice Address - Street 1:971 LAKELAND DRIVE
Practice Address - Street 2:SUITE 1157
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-6900
Practice Address - Fax:601-362-6111
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR576867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500000666Medicare ID - Type UnspecifiedMEDICARE -MYERS
MSP03189Medicare UPIN