Healthcare Provider Details

I. General information

NPI: 1619108206
Provider Name (Legal Business Name): MELODI LYNNE LEWIS-CARVOUR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CURTIS PKWY NE SUITE 1
CALHOUN GA
30701-2062
US

IV. Provider business mailing address

1434 BROADRICK DR
DALTON GA
30720-3009
US

V. Phone/Fax

Practice location:
  • Phone: 706-879-5770
  • Fax: 706-624-4336
Mailing address:
  • Phone: 706-278-5961
  • Fax: 706-275-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number280
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 2660
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: