Provider Demographics
NPI:1124494505
Name:CARROLL, JANET (RN, MT)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N BEND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1753
Mailing Address - Country:US
Mailing Address - Phone:260-436-8807
Mailing Address - Fax:260-436-2767
Practice Address - Street 1:5111 N BEND DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1753
Practice Address - Country:US
Practice Address - Phone:260-436-8807
Practice Address - Fax:260-436-2767
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28057959A163WM1400X
INMT20901877225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT20901877OtherMASSAGE THERAPIST
IN28057959AOtherREGISTERED NURSE