Provider Demographics
NPI:1649593500
Name:CARROLL, NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8515
Mailing Address - Country:US
Mailing Address - Phone:814-226-3470
Mailing Address - Fax:814-226-3479
Practice Address - Street 1:21159 PAINT BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHIPPENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16254-4023
Practice Address - Country:US
Practice Address - Phone:814-226-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026314130003Medicaid