Provider Demographics
NPI:1588279913
Name:CARPENTER, MINDY MARIE
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:MARIE
Last Name:CARPENTER
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 1:6703 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:OH
Mailing Address - Zip Code:45368-9632
Mailing Address - Country:US
Mailing Address - Phone:937-536-9436
Mailing Address - Fax:
Practice Address - Street 1:6703 LONDON RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:OH
Practice Address - Zip Code:45368-9632
Practice Address - Country:US
Practice Address - Phone:937-536-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1204789171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1204789Medicaid