Provider Demographics
NPI:1609079110
Name:DEHAVEN, CAROL JEAN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:JEAN
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:CNM
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Mailing Address - Street 1:PO BOX 1536
Mailing Address - Street 2:6600 HAWKINS GATE ROAD
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-1536
Mailing Address - Country:US
Mailing Address - Phone:301-392-9722
Mailing Address - Fax:
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-8599
Practice Address - Fax:301-475-1514
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDR063454367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife