Provider Demographics
NPI:1689666778
Name:TIMMONS, CAROL (FNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TIMMONS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:SWAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:109 N SHELBY ST
Mailing Address - Street 2:PO BOX 132
Mailing Address - City:CLARENCE
Mailing Address - State:MO
Mailing Address - Zip Code:63437-1712
Mailing Address - Country:US
Mailing Address - Phone:573-469-2084
Mailing Address - Fax:660-699-2243
Practice Address - Street 1:109 N SHELBY ST
Practice Address - Street 2:PO BOX 132
Practice Address - City:CLARENCE
Practice Address - State:MO
Practice Address - Zip Code:63437-1712
Practice Address - Country:US
Practice Address - Phone:573-469-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO092882363LG0600X
MO0327043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423945419Medicaid
MO423945419Medicaid