Provider Demographics
NPI:1295908341
Name:CARPENTER, PATRICIA ANN
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:CARPENTER
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 1:130 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3900
Mailing Address - Country:US
Mailing Address - Phone:815-965-2989
Mailing Address - Fax:
Practice Address - Street 1:130 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3900
Practice Address - Country:US
Practice Address - Phone:815-965-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL23903228156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1295290001OtherBILLING PROVIDER