Provider Demographics
NPI:1982389045
Name:DOUGLAS, CAROL DIANNE (RN LIC# 19836)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:DIANNE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RN LIC# 19836
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MANDAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4314
Mailing Address - Country:US
Mailing Address - Phone:304-677-4059
Mailing Address - Fax:
Practice Address - Street 1:105 MANDAN RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-4314
Practice Address - Country:US
Practice Address - Phone:304-677-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19836163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse