Provider Demographics
NPI:1770686909
Name:HARTMAN, CAROL GANNON (CPNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:GANNON
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13832 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1305
Mailing Address - Country:US
Mailing Address - Phone:301-854-1513
Mailing Address - Fax:202-476-2440
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:ROOM M3551
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:202-476-3789
Practice Address - Fax:202-476-2440
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCRN40487363LP0200X
MDR127953363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCS54015Medicare UPIN