Provider Demographics
NPI:1700017944
Name:MCTAVISH, CAROL MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARIE
Last Name:MCTAVISH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MEYER ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2231
Mailing Address - Country:US
Mailing Address - Phone:617-325-7450
Mailing Address - Fax:
Practice Address - Street 1:36 MEYER ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2231
Practice Address - Country:US
Practice Address - Phone:617-325-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54155164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse