Provider Demographics
NPI:1588296750
Name:CARLYLE, JAMIE NICOLE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:CARLYLE
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 1:1745 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5748
Mailing Address - Country:US
Mailing Address - Phone:770-922-0447
Mailing Address - Fax:
Practice Address - Street 1:1745 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5748
Practice Address - Country:US
Practice Address - Phone:770-922-0447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0245671835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist