Provider Demographics
NPI:1194273235
Name:HARRELL, CAROL
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:HARRELL
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:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:GA
Mailing Address - Zip Code:31782-0156
Mailing Address - Country:US
Mailing Address - Phone:229-869-3094
Mailing Address - Fax:
Practice Address - Street 1:4110 HARDAWAY RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-8746
Practice Address - Country:US
Practice Address - Phone:229-869-3094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA171W00000XMedicaid