Provider Demographics
NPI:1669557112
Name:CARRENO, SUSAN RENEE
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RENEE
Last Name:CARRENO
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 1:5673 DEXTERS MILL PL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2292
Mailing Address - Country:US
Mailing Address - Phone:678-687-3866
Mailing Address - Fax:678-546-1879
Practice Address - Street 1:5673 DEXTERS MILL PL
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-2292
Practice Address - Country:US
Practice Address - Phone:678-687-3866
Practice Address - Fax:678-546-1879
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA280347058AMedicaid