Provider Demographics
NPI:1649636945
Name:CARROLL, DANA (ARNP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ARNP
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 576
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0576
Mailing Address - Country:US
Mailing Address - Phone:352-978-2239
Mailing Address - Fax:
Practice Address - Street 1:133 BENMORE DR STE 200
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4111
Practice Address - Country:US
Practice Address - Phone:407-646-7070
Practice Address - Fax:407-646-7747
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3409322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020281000Medicaid