Provider Demographics
NPI:1245266865
Name:SUTTLES, CARISSA JANINE (DC)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:JANINE
Last Name:SUTTLES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:CARISSA
Other - Middle Name:JANINE
Other - Last Name:GANNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1012 EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635-4404
Mailing Address - Country:US
Mailing Address - Phone:706-410-0390
Mailing Address - Fax:
Practice Address - Street 1:1441 HARTWELL HWY
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-3405
Practice Address - Country:US
Practice Address - Phone:706-340-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019874111N00000X
GACHIR007885111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5681390001Medicare NSC