Healthcare Provider Details

I. General information

NPI: 1003720723
Provider Name (Legal Business Name): CARMELITA DENNIS BLOUNT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9042 HOLDER RD
LOCUST GROVE GA
30248-4608
US

IV. Provider business mailing address

9042 HOLDER RD
LOCUST GROVE GA
30248-4608
US

V. Phone/Fax

Practice location:
  • Phone: 770-883-9413
  • Fax:
Mailing address:
  • Phone: 770-883-9413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0901X
TaxonomyDiplomate Laboratory Management Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: