Provider Demographics
NPI:1821599549
Name:FUQUAY, CAROLYN (RN)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:FUQUAY
Suffix:
Gender:F
Credentials:RN
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 901
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75657-0901
Mailing Address - Country:US
Mailing Address - Phone:903-665-6131
Mailing Address - Fax:903-665-7244
Practice Address - Street 1:120 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:TX
Practice Address - Zip Code:75657-1934
Practice Address - Country:US
Practice Address - Phone:903-665-6131
Practice Address - Fax:903-665-7244
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX637660163W00000X, 163WC0400X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management