Provider Demographics
NPI:1902042799
Name:MOORE, CHARLSIE FAITH (RN)
Entity Type:Individual
Prefix:MS
First Name:CHARLSIE
Middle Name:FAITH
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 BETHLEHEM CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GRANTVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30220-1835
Mailing Address - Country:US
Mailing Address - Phone:770-820-5438
Mailing Address - Fax:
Practice Address - Street 1:1545 BETHLEHEM CHURCH RD
Practice Address - Street 2:
Practice Address - City:GRANTVILLE
Practice Address - State:GA
Practice Address - Zip Code:30220-1835
Practice Address - Country:US
Practice Address - Phone:770-820-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-28
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168618163W00000X
VA0001200802163W00000X
NC200020163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse