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General NPI Number Information
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NPI Number | 1366294712
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Entity Type | Individual
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Provider Name | ELBRETTA RENISE CARPENTER
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Gender | Female
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Dates
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Enumeration Date | 04/01/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 3117 BENTLEY FARMS DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-3175
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Country | US
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Telephone | 470-475-6911
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Fax |
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Provider Business Mailing Address
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Address Line | 226 ALCOVY ST STE A4
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City | MONROE
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State | GA
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Zip | 30655-2184
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Country | US
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Telephone | 770-241-6905
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | COO87445
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License Number State | GA
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