Provider Demographics
NPI:1922058643
Name:CREEKMORE, CARLA M (CRNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:M
Last Name:CREEKMORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:MC
Other - Last Name:FRITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:500 GREENE ST
Mailing Address - Street 2:CHILDREN'S MEDICAL GROUP
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2755
Mailing Address - Country:US
Mailing Address - Phone:301-724-7616
Mailing Address - Fax:301-724-4811
Practice Address - Street 1:5211 COMMERCE CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-2183
Practice Address - Country:US
Practice Address - Phone:502-966-3918
Practice Address - Fax:502-969-3665
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR139268363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409219800Medicaid
MD409219800Medicaid