Healthcare Provider Details

I. General information

NPI: 1497974414
Provider Name (Legal Business Name): GLORIA J CARUSI APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LLOYD AVE
TYRONE GA
30290-2124
US

IV. Provider business mailing address

110 LLOYD AVE
TYRONE GA
30290-2124
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-1200
  • Fax: 770-486-3697
Mailing address:
  • Phone: 770-486-1200
  • Fax: 770-486-3697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN044369 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: