Provider Demographics
NPI:1366294712
Name:CARPENTER, ELBRETTA RENISE
Entity type:Individual
Prefix:
First Name:ELBRETTA
Middle Name:RENISE
Last Name:CARPENTER
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 1:226 ALCOVY ST STE A4
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2184
Mailing Address - Country:US
Mailing Address - Phone:770-241-6905
Mailing Address - Fax:
Practice Address - Street 1:3117 BENTLEY FARMS DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3175
Practice Address - Country:US
Practice Address - Phone:470-475-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOO87445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist