Provider Demographics
NPI:1285223693
Name:SMITH, CHARISE
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 COBBLESTONE TRL
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1224
Mailing Address - Country:US
Mailing Address - Phone:404-492-2831
Mailing Address - Fax:
Practice Address - Street 1:215 COBBLESTONE TRL
Practice Address - Street 2:
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002-1224
Practice Address - Country:US
Practice Address - Phone:404-310-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN157509163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse