Provider Demographics
NPI:1336827740
Name:ILLUM, CARRIE B
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
Last Name:ILLUM
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 1:158 SPIDER BARNES RD
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-6333
Mailing Address - Country:US
Mailing Address - Phone:970-988-7100
Mailing Address - Fax:
Practice Address - Street 1:917 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6527
Practice Address - Country:US
Practice Address - Phone:423-439-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program