Provider Demographics
NPI:1689208209
Name:KVIETKUS, CAROLINA JUNE
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:JUNE
Last Name:KVIETKUS
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 1:3400C OLD MILTON PKWY STE 270
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4438
Mailing Address - Country:US
Mailing Address - Phone:770-442-1911
Mailing Address - Fax:
Practice Address - Street 1:3400C OLD MILTON PKWY STE 270
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4438
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program