Provider Demographics
NPI:1891911566
Name:MARCUM, CAROL RENEE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:RENEE
Last Name:MARCUM
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 1:155 MIZE BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6632
Mailing Address - Country:US
Mailing Address - Phone:606-598-4667
Mailing Address - Fax:
Practice Address - Street 1:155 MIZE BRANCH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6632
Practice Address - Country:US
Practice Address - Phone:606-598-4667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R1597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist