Provider Demographics
NPI:1235658154
Name:DECKELMANN, CHARISSA (CPNP)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:DECKELMANN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1060
Mailing Address - Country:US
Mailing Address - Phone:404-785-6395
Mailing Address - Fax:404-785-1994
Practice Address - Street 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:404-785-6395
Practice Address - Fax:404-785-1994
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292385363LP0200X
MO2019030576363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner