Provider Demographics
NPI:1609960343
Name:CARROLL, KRISTY DAWN (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:DAWN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 KNOB OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-8932
Mailing Address - Country:US
Mailing Address - Phone:936-581-1748
Mailing Address - Fax:936-291-1625
Practice Address - Street 1:12621 HIGHWAY 105 W
Practice Address - Street 2:104
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1506
Practice Address - Country:US
Practice Address - Phone:936-447-6020
Practice Address - Fax:832-559-8584
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX665834363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J4760Medicare PIN