Provider Demographics
NPI:1649439373
Name:SWAN, CAROLYN DIANE
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:DIANE
Last Name:SWAN
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 1:417 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JULIAETTA
Mailing Address - State:ID
Mailing Address - Zip Code:83535-5003
Mailing Address - Country:US
Mailing Address - Phone:208-276-3174
Mailing Address - Fax:
Practice Address - Street 1:417 MAIN ST
Practice Address - Street 2:
Practice Address - City:JULIAETTA
Practice Address - State:ID
Practice Address - Zip Code:83535-5003
Practice Address - Country:US
Practice Address - Phone:208-276-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFH20165171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807843600Medicaid