Provider Demographics
NPI:1407030893
Name:DAVID, CAROLYN GENEVIEVE
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:GENEVIEVE
Last Name:DAVID
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 1:4416 PORPOISE DR
Mailing Address - Street 2:4416 PORPOISE DR.
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-8316
Mailing Address - Country:US
Mailing Address - Phone:813-988-8408
Mailing Address - Fax:
Practice Address - Street 1:4416 PORPOISE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-8316
Practice Address - Country:US
Practice Address - Phone:813-988-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home