MEDICARE: DAWN RACHELLE CARTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	652152	GA

General Provider Information

NPI Number	:	1205058161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN RACHELLE CARTER

Provider Business Mailing Address
First Line	:	19 LANVALE ST
Second Line	:
City	:	PORT WENTWORTH
State	:	GA
Zip	:	31407-9763
Country	:	US
Telephone Number	:	912-963-6742
Fax Number	:	912-963-0874

Provider Business Practice Location Address
First Line	:	19 LANVALE ST
Second Line	:
City	:	PORT WENTWORTH
State	:	GA
Zip	:	31407-9763
Country	:	US
Telephone Number	:	912-963-6742
Fax Number	:	912-963-0874

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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