Provider Demographics
NPI:1285286419
Name:CARROLL, MYESHIA LA'TWAY (DNP)
Entity type:Individual
Prefix:DR
First Name:MYESHIA
Middle Name:LA'TWAY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:PINEHILL
Mailing Address - State:NM
Mailing Address - Zip Code:87357-0404
Mailing Address - Country:US
Mailing Address - Phone:850-445-7499
Mailing Address - Fax:
Practice Address - Street 1:INDIAN SERVICE RTE 140 & INDIAN SERVICE RTE 125
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NM
Practice Address - Zip Code:87357
Practice Address - Country:US
Practice Address - Phone:505-775-3271
Practice Address - Fax:505-775-3633
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA282580363LF0000X
FL9270337363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily