Provider Demographics
NPI:1245273325
Name:CARLSON, RONELL JEAN (FNP)
Entity type:Individual
Prefix:
First Name:RONELL
Middle Name:JEAN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13276
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79768-3276
Mailing Address - Country:US
Mailing Address - Phone:432-631-2300
Mailing Address - Fax:
Practice Address - Street 1:4222 WENDOVER AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5945
Practice Address - Country:US
Practice Address - Phone:432-552-5656
Practice Address - Fax:432-552-0992
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX532880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164838801Medicaid
TXS68706Medicare UPIN
TX8B8615Medicare PIN