Provider Demographics
NPI:1013272616
Name:KING, CARLA RENEE (CNM)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RENEE
Last Name:KING
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 232
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-277-8988
Mailing Address - Fax:937-277-9035
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:SUITE 232
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-277-8988
Practice Address - Fax:937-277-9035
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9381412367A00000X
OHCOA13322NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112672Medicaid