Provider Demographics
NPI:1114322419
Name:GUILLAUME, CHARLES (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GUILLAUME
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 ATHENS HWY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1768
Mailing Address - Country:US
Mailing Address - Phone:678-254-0917
Mailing Address - Fax:888-627-6444
Practice Address - Street 1:500 PLANTATION PARK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4144
Practice Address - Country:US
Practice Address - Phone:678-344-8268
Practice Address - Fax:888-627-6444
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180218363LP0808X
GA180218363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology