Provider Demographics
NPI:1669706438
Name:ETIENNE, CAROL JEAN (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:J
Other - Last Name:BERTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7722 W STATE ROAD 66
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:812-853-6166
Mailing Address - Fax:
Practice Address - Street 1:7722 W STATE ROAD 66
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630
Practice Address - Country:US
Practice Address - Phone:812-853-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003096A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN249390002Medicare PIN