Provider Demographics
NPI:1851959571
Name:CASTLEBERRY, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:CASTLEBERRY
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 1:599 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39827-5114
Mailing Address - Country:US
Mailing Address - Phone:229-516-3345
Mailing Address - Fax:
Practice Address - Street 1:1350 13TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-3203
Practice Address - Country:US
Practice Address - Phone:904-627-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9280372163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty