Provider Demographics
NPI:1477050672
Name:PROM, CARRI ROSE (NP)
Entity Type:Individual
Prefix:
First Name:CARRI
Middle Name:ROSE
Last Name:PROM
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 1:9663 SANTA MONICA BLVD # 1151
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4303
Mailing Address - Country:US
Mailing Address - Phone:818-922-2244
Mailing Address - Fax:
Practice Address - Street 1:250 N ROBERTSON BLVD STE 106A
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1767
Practice Address - Country:US
Practice Address - Phone:818-922-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI196026-30163WE0003X
CA849992163WG0000X
CA95009386363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice