Provider Demographics
NPI:1053996181
Name:PLUMB, CARMEN HEATHER
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:HEATHER
Last Name:PLUMB
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 1:3651 FREY LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2032
Mailing Address - Country:US
Mailing Address - Phone:310-994-3937
Mailing Address - Fax:
Practice Address - Street 1:3651 FREY LAKE RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2032
Practice Address - Country:US
Practice Address - Phone:310-994-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36223225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist