Healthcare Provider Details

I. General information

NPI: 1871163311
Provider Name (Legal Business Name): LORRIN ELIZABETH MORTIMER CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORRIN ELIZABETH MORTIMER

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

645 HARRIS RD
FAYETTEVILLE GA
30215-7412
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-7000
  • Fax:
Mailing address:
  • Phone: 404-401-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number10620
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: