Provider Demographics
NPI:1154085629
Name:FULLWOOD, CHARISSE N (PMHNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:CHARISSE
Middle Name:N
Last Name:FULLWOOD
Suffix:
Gender:F
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 1:10901 WORLD TRADE BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4203
Mailing Address - Country:US
Mailing Address - Phone:919-372-4408
Mailing Address - Fax:
Practice Address - Street 1:10901 WORLD TRADE BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4203
Practice Address - Country:US
Practice Address - Phone:919-372-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health