Provider Demographics
NPI:1578816484
Name:CHARLES, MELODY A (RD, PA-C)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:CHARLES
Suffix:
Gender:F
Credentials:RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PEACHTREE ST NE STE 1470
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2242
Mailing Address - Country:US
Mailing Address - Phone:404-589-2670
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE STE 1470
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2242
Practice Address - Country:US
Practice Address - Phone:404-589-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
GA9905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered