Provider Demographics
NPI:1205056934
Name:MERSEREAU, CAROL ANN (DIPL AC)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:MERSEREAU
Suffix:
Gender:F
Credentials:DIPL AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:MOOSE
Mailing Address - State:WY
Mailing Address - Zip Code:83012-0331
Mailing Address - Country:US
Mailing Address - Phone:307-733-0507
Mailing Address - Fax:
Practice Address - Street 1:280 EAST BROADWAY
Practice Address - Street 2:SUITE 806
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
002874OtherNCCAOM