Provider Demographics
NPI:1588025738
Name:CARLOS, CAROLYN
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:CARLOS
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:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:TOGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99678-0028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 KANAKANAK ROAD
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576-0130
Practice Address - Country:US
Practice Address - Phone:907-842-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK99-265-IV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker