Healthcare Provider Details

I. General information

NPI: 1174108666
Provider Name (Legal Business Name): CAROLINA MARIE COLON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL BLVD STE 310
ROSWELL GA
30076-4947
US

IV. Provider business mailing address

2500 HOSPITAL BLVD STE 310
ROSWELL GA
30076-4947
US

V. Phone/Fax

Practice location:
  • Phone: 770-764-9600
  • Fax:
Mailing address:
  • Phone: 770-664-9600
  • Fax: 770-664-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12945
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: