Provider Demographics
NPI:1790393205
Name:CARPENTER, MARVA GRACE (APRN)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:GRACE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 PELICAN DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6164
Mailing Address - Country:US
Mailing Address - Phone:561-797-6278
Mailing Address - Fax:
Practice Address - Street 1:3387 S JOG RD STE 103
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2010
Practice Address - Country:US
Practice Address - Phone:561-781-8090
Practice Address - Fax:561-781-8099
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008625163W00000X, 363LF0000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110079200Medicaid