Provider Demographics
NPI:1790885507
Name:MACHOLD, CAROLYN MARIE (CNS,CRNFA,RNFA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MARIE
Last Name:MACHOLD
Suffix:
Gender:F
Credentials:CNS,CRNFA,RNFA
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 42123
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-2123
Mailing Address - Country:US
Mailing Address - Phone:520-318-6039
Mailing Address - Fax:520-320-0081
Practice Address - Street 1:1140 E CALLE MARIPOSA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-2952
Practice Address - Country:US
Practice Address - Phone:520-318-6039
Practice Address - Fax:520-320-0081
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ042232174400000X
AZRN040651163WM0705X
AZ026364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
No174400000XOther Service ProvidersSpecialist
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ184995Medicaid
AZZ60126OtherMEDICAREPTAN
AZZ60126OtherMEDICAREPTAN