Provider Demographics
NPI:1912987124
Name:CARLSON, NICOLE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N BROAD STREET EXT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4603
Mailing Address - Country:US
Mailing Address - Phone:724-449-3245
Mailing Address - Fax:724-449-3233
Practice Address - Street 1:631 N BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4603
Practice Address - Country:US
Practice Address - Phone:724-449-3245
Practice Address - Fax:724-449-3233
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056758207V00000X
WV28269207V00000X
PAMD430168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology