Provider Demographics
NPI:1386906691
Name:CARROLL, ROBERT A (CNA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MARKET ST # 335
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1928
Mailing Address - Country:US
Mailing Address - Phone:573-592-7870
Mailing Address - Fax:888-550-9399
Practice Address - Street 1:5080 DARO DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-3871
Practice Address - Country:US
Practice Address - Phone:573-592-7870
Practice Address - Fax:888-550-9399
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO130047B376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide