Provider Demographics
NPI:1063181741
Name:CARROLL, TIA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:CARROLL
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 1:9798 MUSKET RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-6712
Mailing Address - Country:US
Mailing Address - Phone:404-388-9209
Mailing Address - Fax:
Practice Address - Street 1:9798 MUSKET RIDGE CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-6712
Practice Address - Country:US
Practice Address - Phone:404-388-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN163876163WC0400X, 163WC1500X, 163WH0200X, 163WW0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care