Provider Demographics
NPI:1811216138
Name:CARROLL, SAM (LPN)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12047 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1891
Mailing Address - Country:US
Mailing Address - Phone:216-228-0158
Mailing Address - Fax:
Practice Address - Street 1:12047 LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1891
Practice Address - Country:US
Practice Address - Phone:216-228-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN091042164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse