Provider Demographics
NPI:1609808302
Name:KNICKERBOCKER, CAROL A (WHCNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:SOCHOUKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:262 HARLOW ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4952
Mailing Address - Country:US
Mailing Address - Phone:207-973-3656
Mailing Address - Fax:207-941-2978
Practice Address - Street 1:262 HARLOW ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4952
Practice Address - Country:US
Practice Address - Phone:207-973-3656
Practice Address - Fax:207-941-2978
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER017530363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMK0004173OtherDEA
MES50992Medicare UPIN