=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659086296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL THOMISON MSN, AGPCNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 PARK CITY RD
-----------------------------------------------------
City | ROSSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30741-3980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-355-9681
-----------------------------------------------------
Fax | 781-384-6201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 TRAIL LAKE DR
-----------------------------------------------------
City | LA FAYETTE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30728-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-355-9681
-----------------------------------------------------
Fax | 781-384-6201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 32976
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | RN247679
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------