Provider Demographics
NPI:1427513746
Name:CARROLL, HARRY W IV (FNP)
Entity type:Individual
Prefix:MR
First Name:HARRY
Middle Name:W
Last Name:CARROLL
Suffix:IV
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3040 N WICKHAM RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2369
Mailing Address - Country:US
Mailing Address - Phone:321-456-9653
Mailing Address - Fax:321-204-9168
Practice Address - Street 1:3040 N WICKHAM RD STE 3
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-456-9653
Practice Address - Fax:321-204-9168
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001267363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily