Provider Demographics
NPI:1447342688
Name:FENELUS, CARLINE A (PA)
Entity type:Individual
Prefix:MRS
First Name:CARLINE
Middle Name:A
Last Name:FENELUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:CARLINE
Other - Middle Name:ARIOL
Other - Last Name:FENELUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:12493 HUNTINGTON TRACE LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-8799
Mailing Address - Country:US
Mailing Address - Phone:678-242-0332
Mailing Address - Fax:678-242-0332
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:706-544-8830
Practice Address - Fax:762-408-8169
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005311-01363A00000X
GA004624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD000Medicare UPIN