Provider Demographics
NPI:1629616271
Name:CARPENTER, ANN ELIZABETH
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:CARPENTER
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 1:1037 LANAI ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-0074
Mailing Address - Country:US
Mailing Address - Phone:503-851-9087
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST STE 333
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1996
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR201130414LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse