Provider Demographics
NPI:1558167627
Name:CARROLL, KATHLEEN ANITA
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANITA
Last Name:CARROLL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MO
Mailing Address - Zip Code:64439-0064
Mailing Address - Country:US
Mailing Address - Phone:816-807-4808
Mailing Address - Fax:
Practice Address - Street 1:107 NORTH MAY STREET
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MO
Practice Address - Zip Code:64439-6443
Practice Address - Country:US
Practice Address - Phone:816-807-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care