Provider Demographics
NPI:1104241686
Name:RAINES, CARMEN R (FNP-C)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:R
Last Name:RAINES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:R
Other - Last Name:MCDIVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1265 CLIFF GOOKIN BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6749
Mailing Address - Country:US
Mailing Address - Phone:662-840-2131
Mailing Address - Fax:662-840-2522
Practice Address - Street 1:1265 CLIFF GOOKIN BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6749
Practice Address - Country:US
Practice Address - Phone:662-840-2131
Practice Address - Fax:662-840-2522
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR829034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily