Provider Demographics
NPI:1437877305
Name:O'MEARA, CARLIE
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:O'MEARA
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 1:203 BETHANY CREEK BND
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3339
Mailing Address - Country:US
Mailing Address - Phone:203-650-1162
Mailing Address - Fax:
Practice Address - Street 1:306 SPOTTED RIDGE CIR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2625
Practice Address - Country:US
Practice Address - Phone:203-650-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN314370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA33568332Medicaid