Provider Demographics
NPI:1447236526
Name:CARLSON, MARY I (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:I
Last Name:CARLSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HITCHCOCK WAY
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - PEDIATRICS
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104
Mailing Address - Country:US
Mailing Address - Phone:603-695-2597
Mailing Address - Fax:
Practice Address - Street 1:444 NASHUA ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055
Practice Address - Country:US
Practice Address - Phone:603-673-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH029057-23363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008542Medicaid