Provider Demographics
NPI:1780703306
Name:DESANDRE, CAROLYNN ANNE (PHD, CMN, FNP-BC)
Entity type:Individual
Prefix:
First Name:CAROLYNN
Middle Name:ANNE
Last Name:DESANDRE
Suffix:
Gender:F
Credentials:PHD, CMN, FNP-BC
Other - Prefix:
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Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5600
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:134 ANSLEY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1640
Practice Address - Country:US
Practice Address - Phone:706-864-2155
Practice Address - Fax:706-374-7628
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN113863367A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133660BMedicaid