Provider Demographics
NPI:1982180378
Name:CARROLL, BRIAN DOUGLAS (RN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:CARROLL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 ELLIPSE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7450
Mailing Address - Country:US
Mailing Address - Phone:772-359-7246
Mailing Address - Fax:
Practice Address - Street 1:4434 ELLIPSE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7450
Practice Address - Country:US
Practice Address - Phone:772-359-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95113212163W00000X
WARN60682202163W00000X
MN239908-1163W00000X
FLRN2970412163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse