Provider Demographics
NPI:1164970661
Name:MWANGI, CAROLYN LIZZY
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LIZZY
Last Name:MWANGI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 MOUNT SINAI DR
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-2367
Mailing Address - Country:US
Mailing Address - Phone:404-797-7442
Mailing Address - Fax:
Practice Address - Street 1:330 MOUNT SINAI DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-2367
Practice Address - Country:US
Practice Address - Phone:404-797-7442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN209788OtherGEORGIA BOARD OF NURSING LICENSE