Provider Demographics
NPI:1295054054
Name:CHURCH, CARLA SUE (DO)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4501 S 70TH ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4201
Mailing Address - Country:US
Mailing Address - Phone:402-484-5100
Mailing Address - Fax:402-484-5151
Practice Address - Street 1:4501 S 70TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4201
Practice Address - Country:US
Practice Address - Phone:402-484-5100
Practice Address - Fax:402-484-5151
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE844207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program