Provider Demographics
NPI:1609288141
Name:CARDEN, NICOLE ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELISE
Last Name:CARDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-705-0260
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:50 PARKWAY LN STE C
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-705-0260
Practice Address - Fax:601-261-3583
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25302208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04575251Medicaid