Healthcare Provider Details

I. General information

NPI: 1780081661
Provider Name (Legal Business Name): CARROLL MARIE KELLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 WASHINGTON COMMONS DR
EVANS GA
30809-3170
US

IV. Provider business mailing address

1801 MARYLAND AVE
AUGUSTA GA
30904-5316
US

V. Phone/Fax

Practice location:
  • Phone: 706-231-5552
  • Fax:
Mailing address:
  • Phone: 706-231-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN113796
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberRN113796
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberRN113796
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: