Provider Demographics
NPI:1649001637
Name:SMITH, CHARISSA N
Entity type:Individual
Prefix:MISS
First Name:CHARISSA
Middle Name:N
Last Name:SMITH
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 1:1718 ANN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2114
Mailing Address - Country:US
Mailing Address - Phone:910-547-0322
Mailing Address - Fax:
Practice Address - Street 1:1718 ANN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2114
Practice Address - Country:US
Practice Address - Phone:910-547-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker