Provider Demographics
NPI:1306567854
Name:CARROLL, KATHERINE (CPNP-PC/AC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CPNP-PC/AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20782-2155
Mailing Address - Country:US
Mailing Address - Phone:610-357-5867
Mailing Address - Fax:
Practice Address - Street 1:6509 41ST AVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:MD
Practice Address - Zip Code:20782-2155
Practice Address - Country:US
Practice Address - Phone:610-357-5867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNP1052429363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics