Provider Demographics
NPI:1992924971
Name:CRUISE, PHN, CAROL ANN (RN, PHN, BSN)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:CRUISE, PHN
Suffix:
Gender:F
Credentials:RN, PHN, BSN
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANNE
Other - Last Name:CRUISE, PHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, PHN, BSN
Mailing Address - Street 1:1175 BEL ARBRES DR
Mailing Address - Street 2:
Mailing Address - City:REDWOOD VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95470-9695
Mailing Address - Country:US
Mailing Address - Phone:707-485-0129
Mailing Address - Fax:
Practice Address - Street 1:1175 BEL ARBRES DR
Practice Address - Street 2:
Practice Address - City:REDWOOD VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95470-9695
Practice Address - Country:US
Practice Address - Phone:707-485-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 139146163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP161897Medicaid