Provider Demographics
NPI:1154318913
Name:WATSON, CAROLYN M (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:WATSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:WATSON-PATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3155 N POINT PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5481
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:SUITE 302
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:678-574-0943
Practice Address - Fax:678-574-0943
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN111560367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000576727CMedicaid
GA511I430198Medicare PIN
GA000576727CMedicaid
GA43ZCBXF25Medicare PIN