Provider Demographics
NPI:1255909719
Name:CARLSON, EMILY ELIZABETH
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ELIZABETH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 W BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-2234
Mailing Address - Country:US
Mailing Address - Phone:928-241-8150
Mailing Address - Fax:
Practice Address - Street 1:208 E PINE KNOLL DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86011-2234
Practice Address - Country:US
Practice Address - Phone:928-241-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No124Q00000XDental ProvidersDental Hygienist