Provider Demographics
NPI:1194996017
Name:LANTZ, CARLA MARIE (CNM)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:MARIE
Last Name:LANTZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 E TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1131
Mailing Address - Country:US
Mailing Address - Phone:417-831-0150
Mailing Address - Fax:
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-447-0573
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006948367A00000X
MO137762367A00000X
ARM02113CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001Medicare NSC