Provider Demographics
NPI:1992432280
Name:ETTER, CARLIE LANE
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:LANE
Last Name:ETTER
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 1:1320 EASTERN CT
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 EASTERN CT
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8708
Practice Address - Country:US
Practice Address - Phone:765-745-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant