Provider Demographics
NPI:1538432489
Name:BLACKMORE, CAROLYN I (RN)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:I
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2310 VILLA POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9239
Mailing Address - Country:US
Mailing Address - Phone:678-836-8874
Mailing Address - Fax:770-478-8722
Practice Address - Street 1:853 BATTLECREEK RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1919
Practice Address - Country:US
Practice Address - Phone:770-478-1099
Practice Address - Fax:770-478-8722
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN083571163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health