Provider Demographics
NPI:1538874136
Name:DELOACH, CAROLYN L (CNA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
Last Name:DELOACH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 VIVIENDA DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4359
Mailing Address - Country:US
Mailing Address - Phone:941-586-3734
Mailing Address - Fax:
Practice Address - Street 1:6104 VIVIENDA DR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-4359
Practice Address - Country:US
Practice Address - Phone:941-586-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237317376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker