Provider Demographics
NPI:1982372587
Name:LADD CARRELL, TOMMI AMANDA
Entity Type:Individual
Prefix:
First Name:TOMMI
Middle Name:AMANDA
Last Name:LADD CARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TOMMI
Other - Middle Name:AMANDA
Other - Last Name:LADD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3230 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-5950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1197 FORTUNE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7472
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife