Provider Demographics
NPI:1710642129
Name:ETTENBERGER, CARRIE A
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:ETTENBERGER
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 1:20 PAGE DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8847
Mailing Address - Country:US
Mailing Address - Phone:607-368-0075
Mailing Address - Fax:
Practice Address - Street 1:20 PAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8847
Practice Address - Country:US
Practice Address - Phone:910-621-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC91029164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse