Provider Demographics
NPI:1710576707
Name:HARRIS, CHARLYN ANNISE
Entity Type:Individual
Prefix:
First Name:CHARLYN
Middle Name:ANNISE
Last Name:HARRIS
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 1:2865 CHURCHILL ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-5260
Mailing Address - Country:US
Mailing Address - Phone:470-269-2109
Mailing Address - Fax:
Practice Address - Street 1:3060 NAPIER AVE STE B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3872
Practice Address - Country:US
Practice Address - Phone:470-269-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No335E00000XSuppliersProsthetic/Orthotic Supplier