Provider Demographics
NPI:1932414364
Name:CARR, SUSAN RAE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAE
Last Name:CARR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RAE
Other - Last Name:HOLBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-0373
Mailing Address - Country:US
Mailing Address - Phone:304-643-4005
Mailing Address - Fax:304-643-4007
Practice Address - Street 1:135 S PENN AVE
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-1371
Practice Address - Country:US
Practice Address - Phone:304-643-4005
Practice Address - Fax:304-643-4007
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV55537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018904Medicaid
WV2953AMedicare Oscar/Certification