Provider Demographics
NPI:1407140916
Name:PEMBERTON, CARMEN LOREN (NP)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:LOREN
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12412 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6757
Mailing Address - Country:US
Mailing Address - Phone:817-914-1622
Mailing Address - Fax:
Practice Address - Street 1:1245 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7518
Practice Address - Country:US
Practice Address - Phone:817-301-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX590614363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health