Provider Demographics
NPI:1497418529
Name:COFFEY, CHARLEI
Entity Type:Individual
Prefix:
First Name:CHARLEI
Middle Name:
Last Name:COFFEY
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 1:4205 HURON DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-4167
Mailing Address - Country:US
Mailing Address - Phone:678-469-1489
Mailing Address - Fax:
Practice Address - Street 1:1800 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8416
Practice Address - Country:US
Practice Address - Phone:770-886-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACNM07355367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife