Provider Demographics
NPI:1497345219
Name:KROUSE, CAROLYN BACKES (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BACKES
Last Name:KROUSE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 W HAZELHURST ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1887
Mailing Address - Country:US
Mailing Address - Phone:313-434-4277
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704317212363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care