Provider Demographics
NPI:1871644278
Name:HARRIS, CAROLYN M (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 W COUNTY ROAD 200 N
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-9126
Mailing Address - Country:US
Mailing Address - Phone:317-718-7110
Mailing Address - Fax:
Practice Address - Street 1:1045 WYATT WAY
Practice Address - Street 2:
Practice Address - City:LIZTON
Practice Address - State:IN
Practice Address - Zip Code:46149-9583
Practice Address - Country:US
Practice Address - Phone:317-994-6600
Practice Address - Fax:317-994-6605
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28144501A363LC1500X
IN71002313A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100419730Medicaid