Provider Demographics
NPI:1699374777
Name:VAN TOL, CARLENE JO ANN (RN)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:JO ANN
Last Name:VAN TOL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 169
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-0169
Mailing Address - Country:US
Mailing Address - Phone:907-748-5270
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116566163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse