Provider Demographics
NPI:1851441182
Name:DODGE, CARRIE ANN (NP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:DODGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:STRAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:41 MALL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8766
Mailing Address - Fax:781-744-5848
Practice Address - Street 1:41 MALL ROAD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8766
Practice Address - Fax:781-744-5848
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194234363LA2200X
MARN194234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0328162Medicaid
MA110014326AMedicaid
MANP4255Medicare PIN
MA0328162Medicaid