Provider Demographics
NPI:1932701778
Name:BOARDMAN, CARLA (RN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BOARDMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 VIRGINIA ST E STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2175
Mailing Address - Country:US
Mailing Address - Phone:304-343-1130
Mailing Address - Fax:304-343-8944
Practice Address - Street 1:612 VIRGINIA ST E STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2175
Practice Address - Country:US
Practice Address - Phone:304-343-1130
Practice Address - Fax:304-343-8944
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV68779171M00000X
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator