Provider Demographics
NPI:1881356574
Name:CARTER, CORETTA (FNP)
Entity type:Individual
Prefix:
First Name:CORETTA
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 W PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-9041
Mailing Address - Country:US
Mailing Address - Phone:601-391-2716
Mailing Address - Fax:601-391-2717
Practice Address - Street 1:3166 S STATE HIGHWAY 161 STE 170
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7720
Practice Address - Country:US
Practice Address - Phone:972-640-0005
Practice Address - Fax:210-314-5044
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty