Provider Demographics
NPI:1144800020
Name:TIPPETT, CHARLOTTE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ROSE
Last Name:TIPPETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4173 GATESWALK DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5913
Mailing Address - Country:US
Mailing Address - Phone:770-295-9398
Mailing Address - Fax:
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:770-295-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant