Provider Demographics
NPI:1881189702
Name:BEAN, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 BEAVER TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-6037
Mailing Address - Country:US
Mailing Address - Phone:901-315-1084
Mailing Address - Fax:901-249-7686
Practice Address - Street 1:1786 BEAVER TRAIL DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016
Practice Address - Country:US
Practice Address - Phone:901-315-1084
Practice Address - Fax:901-249-7686
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000000023292OtherSTATE LICENSE