Provider Demographics
NPI:1891334074
Name:CARROLL, LACHELLE SOPHIA (REGISTER NURSE)
Entity Type:Individual
Prefix:
First Name:LACHELLE
Middle Name:SOPHIA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:REGISTER NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14046 STAHELIN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14046 STAHELIN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2985
Practice Address - Country:US
Practice Address - Phone:313-549-2916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704347124163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty