Provider Demographics
NPI:1376218073
Name:GRANT, CHARLEE JENNA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLEE
Middle Name:JENNA
Last Name:GRANT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:504 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:762-235-2200
Practice Address - Fax:706-236-6434
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN305600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner