Basic Information
| Provider Information | |||||||||
| NPI: | 1699889865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARBONELL | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14030 CRABAPPLE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784621711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3950 AUSTELL RD | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707324000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 12/30/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 056417 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25112 | AL | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6611384100 | 01 | GA | DOL | OTHER | 244750062D | 05 | GA | MEDICAID | 244750062C | 05 | GA | MEDICAID | 244750062A | 05 | GA | MEDICAID | 244750062B | 05 | GA | MEDICAID |