Provider Demographics
NPI:1245972181
Name:CARLSON, TINA MARIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-1729
Mailing Address - Country:US
Mailing Address - Phone:907-301-8302
Mailing Address - Fax:
Practice Address - Street 1:1105 SE JETTY AVE STE C
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-2604
Practice Address - Country:US
Practice Address - Phone:541-614-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH076986-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily