Provider Demographics
NPI:1902926041
Name:MCDONALD, CAROLYN (CNM)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58887 BREMEN HWY
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6414
Mailing Address - Country:US
Mailing Address - Phone:574-255-6182
Mailing Address - Fax:574-255-6376
Practice Address - Street 1:58887 BREMEN HWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6414
Practice Address - Country:US
Practice Address - Phone:574-255-6182
Practice Address - Fax:574-255-6376
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28130755A163W00000X
MI4704207956163W00000X, 367A00000X
IN09000046A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000277513OtherANTHEM ID NUMBER