Provider Demographics
NPI:1477577567
Name:CARROLL, KATHLEEN LEAH (APN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LEAH
Last Name:CARROLL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:
Practice Address - Street 1:113 PLEASANT VALLEY DR STE 210
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-5683
Practice Address - Country:US
Practice Address - Phone:830-267-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX516229363LG0600X
TXAP115115363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182691901Medicaid
TX8G7249Medicare PIN