Provider Demographics
NPI:1679713747
Name:ANDERSON, CAROLINE (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513
Mailing Address - Country:US
Mailing Address - Phone:912-367-9559
Mailing Address - Fax:912-367-9554
Practice Address - Street 1:278 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0102
Practice Address - Country:US
Practice Address - Phone:912-367-9559
Practice Address - Fax:912-367-9554
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN154703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA329161117AMedicaid