Provider Demographics
NPI:1780157727
Name:CARPENTER, MEGAN GREEN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:GREEN
Last Name:CARPENTER
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 1:216 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9389
Mailing Address - Country:US
Mailing Address - Phone:662-418-9484
Mailing Address - Fax:
Practice Address - Street 1:551 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6733
Practice Address - Country:US
Practice Address - Phone:662-624-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily