Provider Demographics
NPI:1881635373
Name:CUNNINGHAM, CAROLE L (PT)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:L
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-8907
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:455 PHILIP BLVD
Practice Address - Street 2:BLDG 100, STE 160
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8767
Practice Address - Country:US
Practice Address - Phone:678-985-0238
Practice Address - Fax:678-985-0136
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I650047Medicare PIN
GA511I650020Medicare PIN