Provider Demographics
NPI:1972843126
Name:PHILLIPS, CHARLEITTE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLEITTE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 RAPIDS CIR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7993
Mailing Address - Country:US
Mailing Address - Phone:248-778-7656
Mailing Address - Fax:
Practice Address - Street 1:3575 FULTON MILL RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-5125
Practice Address - Country:US
Practice Address - Phone:478-803-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250274163WP0808X
MI4704131775363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health