Provider Demographics
NPI:1982857645
Name:CZARNIAWSKI, CHARISSA MARIA (IDC)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:MARIA
Last Name:CZARNIAWSKI
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:H100 SANTA MARGARITA ROAD
Mailing Address - Street 2:MARINE CORPS BASE CAMP PENDLETON
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-725-7200
Mailing Address - Fax:
Practice Address - Street 1:SMO MAG 39 MEDICAL CG THIRDMAW
Practice Address - Street 2:BOX 555750
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5750
Practice Address - Country:US
Practice Address - Phone:760-725-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710I1002XOtherINDEPENDENT DUTY CORPSMAN