MEDICARE: MS. SUSAN ELAINE CARPENTER RN

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	163WC0400X	Case Management Registered Nurse	RN083881	GA

General Provider Information

NPI Number	:	1639107303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN ELAINE CARPENTER RN

Provider Business Mailing Address
First Line	:	27 WALKING HORSE LN
Second Line	:
City	:	CLEVELAND
State	:	GA
Zip	:	30528-5072
Country	:	US
Telephone Number	:	708-865-7917
Fax Number	:

Provider Business Practice Location Address
First Line	:	3931 MUNDY MILL RD
Second Line	:
City	:	OAKWOOD
State	:	GA
Zip	:	30566-3413
Country	:	US
Telephone Number	:	404-728-8240
Fax Number	:

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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