Provider Demographics
NPI:1699064584
Name:CARNEY, NICOLE LYNN (DO)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:CARNEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 N CHURCH ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 PORTLAND ROAD
Practice Address - Street 2:
Practice Address - City:SO BERWICK
Practice Address - State:ME
Practice Address - Zip Code:04090
Practice Address - Country:US
Practice Address - Phone:207-384-9212
Practice Address - Fax:207-384-2008
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC390200000X
MEDO2464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program