Provider Demographics
NPI:1891221537
Name:CARRUTH, CARLY MCGRAW (FNP-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MCGRAW
Last Name:CARRUTH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 EAGLE SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:FLINTSTONE
Mailing Address - State:GA
Mailing Address - Zip Code:30725-2499
Mailing Address - Country:US
Mailing Address - Phone:706-506-8213
Mailing Address - Fax:
Practice Address - Street 1:165 EAGLE SHADOW DR
Practice Address - Street 2:
Practice Address - City:FLINTSTONE
Practice Address - State:GA
Practice Address - Zip Code:30725-2499
Practice Address - Country:US
Practice Address - Phone:706-506-8213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily