Provider Demographics
NPI:1306237748
Name:VANPUTTEN, CAROL PHYLLIS (AA)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:PHYLLIS
Last Name:VANPUTTEN
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2173 CENTERVILLE PL STE A
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8303
Mailing Address - Country:US
Mailing Address - Phone:850-385-0144
Mailing Address - Fax:850-385-0146
Practice Address - Street 1:2173 CENTERVILLE PL STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8303
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:850-385-0146
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA253367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant