Healthcare Provider Details

I. General information

NPI: 1124085972
Provider Name (Legal Business Name): CARISALYN NICOLE COUSIN APRN BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MEDICAL DR NE
CARTERSVILLE GA
30121-8002
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703
US

V. Phone/Fax

Practice location:
  • Phone: 770-386-1000
  • Fax: 770-386-9165
Mailing address:
  • Phone: 706-602-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP271422
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: