MEDICARE: CARMEN NICOLLE SEZONOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	018478	GA

General Provider Information

NPI Number	:	1508491390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARMEN NICOLLE SEZONOV

Provider Business Mailing Address
First Line	:	910 ATHENS HWY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-4952
Country	:	US
Telephone Number	:	770-554-1111
Fax Number	:	770-554-8717

Provider Business Practice Location Address
First Line	:	910 ATHENS HWY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-4952
Country	:	US
Telephone Number	:	770-554-1111
Fax Number	:	770-554-8717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	03/11/2020

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