Provider Demographics
NPI:1912015298
Name:SCHRADER, CAROLYN ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANN
Last Name:SCHRADER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4361
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4361
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0431
Practice Address - Street 1:409 WILLIS STREET, SUITE 2
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168
Practice Address - Country:US
Practice Address - Phone:601-785-9580
Practice Address - Fax:601-785-9910
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR716324363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07384513Medicaid
MS500002021Medicare ID - Type Unspecified
MSQ57612Medicare UPIN