Healthcare Provider Details

I. General information

NPI: 1114403003
Provider Name (Legal Business Name): MITZI SERENA CARREA FNP-C, RN-NIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 07/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 WHEELER RIDGE RD
DUNLAP TN
37327-4792
US

IV. Provider business mailing address

74 WHEELER RIDGE RD
DUNLAP TN
37327-4792
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-9890
  • Fax:
Mailing address:
  • Phone: 904-652-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24442
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: