Provider Demographics
NPI:1124898291
Name:NEEDHAM, CAROLYN JEAN (FNP-C)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:NEEDHAM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:HARNICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1234 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9750
Mailing Address - Country:US
Mailing Address - Phone:419-344-9156
Mailing Address - Fax:
Practice Address - Street 1:1234 PLANK RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:MI
Practice Address - Zip Code:48131-9750
Practice Address - Country:US
Practice Address - Phone:419-344-9156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner