Provider Demographics
NPI:1114161791
Name:MOORE, CAROLYN MEREDITH (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MEREDITH
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MEREDITH
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7659
Mailing Address - Country:US
Mailing Address - Phone:770-292-4806
Mailing Address - Fax:
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR STE 170
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7668
Practice Address - Country:US
Practice Address - Phone:770-292-4806
Practice Address - Fax:770-292-4808
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170740363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM2295942OtherDEA
GA202I503757Medicare PIN