Healthcare Provider Details

I. General information

NPI: 1790611747
Provider Name (Legal Business Name): CARLA A FANN RT(R)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVE SW
ATLANTA GA
30310-5110
US

IV. Provider business mailing address

304 OAK DR SE
HAPEVILLE GA
30354-2635
US

V. Phone/Fax

Practice location:
  • Phone: 404-230-5682
  • Fax:
Mailing address:
  • Phone: 404-276-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number272350
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: