Provider Demographics
NPI:1780487124
Name:PHELPS, CARMEN MARIE
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MARIE
Last Name:PHELPS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 NW 550TH RD
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64061-9180
Mailing Address - Country:US
Mailing Address - Phone:818-165-8804
Mailing Address - Fax:
Practice Address - Street 1:1956 NW 550TH RD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64061-9180
Practice Address - Country:US
Practice Address - Phone:816-588-0462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024019629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner