Provider Demographics
NPI:1912172081
Name:FERNALD, CARRIE DENISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:DENISE
Last Name:FERNALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 CREEK BED RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8909
Mailing Address - Country:US
Mailing Address - Phone:866-341-7509
Mailing Address - Fax:
Practice Address - Street 1:1540 CREEK BED RD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8909
Practice Address - Country:US
Practice Address - Phone:866-341-7509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003982363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593322AMedicare PIN