Provider Demographics
NPI:1073936928
Name:HERAMB, CAROLINE ALICIA (PA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:ALICIA
Last Name:HERAMB
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1717
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:855-286-3226
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:855-286-3226
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107781363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010495200Medicaid