Provider Demographics
NPI:1386460897
Name:STREET, CARROLTON MACKENZIE
Entity type:Individual
Prefix:
First Name:CARROLTON
Middle Name:MACKENZIE
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 WHITEOAK DR
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35907-7091
Mailing Address - Country:US
Mailing Address - Phone:256-490-1810
Mailing Address - Fax:
Practice Address - Street 1:2950 WHITEOAK DR
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35907-7091
Practice Address - Country:US
Practice Address - Phone:256-490-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant