Provider Demographics
NPI:1194795047
Name:CARSON, JOANN L
Entity type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:L
Last Name:CARSON
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 1:9488 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:770-947-4210
Mailing Address - Fax:770-830-0990
Practice Address - Street 1:160 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4451
Practice Address - Country:US
Practice Address - Phone:770-834-1008
Practice Address - Fax:770-834-2531
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN130954CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA374945OtherB CROSS
GA000716394DOtherMEDICAID X OVER
GA000716394IMedicaid
GA000716394JMedicaid
GA43ZCBXZ05Medicare ID - Type Unspecified
GA000716394JMedicaid