Provider Demographics
NPI:1952075061
Name:CARROLL, KAITLYN WINNIE (PAC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:WINNIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 BLUEBONNET BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-924-2424
Mailing Address - Fax:225-408-7980
Practice Address - Street 1:6550 MAIN ST STE 2300
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4092
Practice Address - Country:US
Practice Address - Phone:225-658-1808
Practice Address - Fax:225-658-5922
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA328192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant