Provider Demographics
NPI:1669094918
Name:CARTER, ELIJAH (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:CARTER
Suffix:
Gender:M
Credentials:FNP-BC
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 269084
Mailing Address - Street 2:DEPT 1102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:
Practice Address - Street 1:1002 GLENVIEW DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3424
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:615-328-3758
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN210485163W00000X
TN29691363LF0000X
KY3018998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN29691OtherSTATE LICENSURE