Provider Demographics
NPI:1154935880
Name:BIVINS, CAROL (AG-NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BIVINS
Suffix:
Gender:F
Credentials:AG-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 AUTUMN RISE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2867
Mailing Address - Country:US
Mailing Address - Phone:414-412-8030
Mailing Address - Fax:
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2042
Practice Address - Country:US
Practice Address - Phone:314-543-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028547363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health