Provider Demographics
NPI:1467215897
Name:AVERY, CARLISSA
Entity Type:Individual
Prefix:
First Name:CARLISSA
Middle Name:
Last Name:AVERY
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 1:722 C ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5206
Mailing Address - Country:US
Mailing Address - Phone:313-828-2399
Mailing Address - Fax:
Practice Address - Street 1:7516 BROOKSHIRE DR
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-3145
Practice Address - Country:US
Practice Address - Phone:313-828-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider