Provider Demographics
NPI:1467066563
Name:BRANNEN, CAROLINE MALONE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MALONE
Last Name:BRANNEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:AMANDA
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3642 N KIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-4316
Mailing Address - Country:US
Mailing Address - Phone:404-281-3058
Mailing Address - Fax:
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD BLDG G
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3001
Practice Address - Country:US
Practice Address - Phone:770-622-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0149342251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT014934OtherGEORGIA STATE BOARD OF PHYSICAL THERAPY