Healthcare Provider Details

I. General information

NPI: 1356915870
Provider Name (Legal Business Name): MICHELLE P CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

4068 ALEXANDER RD
MONTICELLO GA
31064-5055
US

V. Phone/Fax

Practice location:
  • Phone: 770-786-7053
  • Fax:
Mailing address:
  • Phone: 796-476-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN104344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: