Provider Demographics
NPI:1255770616
Name:CARROLL, MANDY (LPN)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAGEE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1011
Mailing Address - Country:US
Mailing Address - Phone:585-797-8964
Mailing Address - Fax:
Practice Address - Street 1:415 MAGEE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-1011
Practice Address - Country:US
Practice Address - Phone:585-797-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311995164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse