Provider Demographics
NPI:1225791262
Name:JEMISON, CAROLYN ROSE (RN)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ROSE
Last Name:JEMISON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ROSE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1410 NEW YORK AVE APT A
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3768
Mailing Address - Country:US
Mailing Address - Phone:850-867-3701
Mailing Address - Fax:
Practice Address - Street 1:525 E 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5412
Practice Address - Country:US
Practice Address - Phone:850-522-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9538329163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9538329OtherLIFE MANAGEMENT CENTER