Provider Demographics
NPI:1639501489
Name:CARPENTER, PHOEBE KITSUM (CNP)
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:KITSUM
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:KITSUM
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 BYERS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3684
Mailing Address - Country:US
Mailing Address - Phone:937-866-2494
Mailing Address - Fax:937-866-8494
Practice Address - Street 1:415 BYERS RD STE 300
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3684
Practice Address - Country:US
Practice Address - Phone:937-866-2494
Practice Address - Fax:937-866-8494
Is Sole Proprietor?:No
Enumeration Date:2013-08-04
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23319363LA2200X, 363LG0600X
OHCOI.15443-NP363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOI.15443-NPOtherOHIO STATE LICENSE
OH0095160Medicaid
OHH230560Medicare PIN