Provider Demographics
NPI:1346861440
Name:GANTT, CHARLIE MURPHY (NP, AGPRN, PMHNP)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:MURPHY
Last Name:GANTT
Suffix:
Gender:M
Credentials:NP, AGPRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 FOREST VIEW CT
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3943
Mailing Address - Country:US
Mailing Address - Phone:248-762-8017
Mailing Address - Fax:
Practice Address - Street 1:32905 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3342
Practice Address - Country:US
Practice Address - Phone:248-957-9184
Practice Address - Fax:248-957-9185
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704317868363LG0600X, 363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care