Provider Demographics
NPI:1740927771
Name:WOOD, CHARMISSE' MONTIKA (LPN, EFDA)
Entity type:Individual
Prefix:
First Name:CHARMISSE'
Middle Name:MONTIKA
Last Name:WOOD
Suffix:
Gender:F
Credentials:LPN, EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 RED BUD RD NE APT H7
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-1994
Mailing Address - Country:US
Mailing Address - Phone:470-861-6896
Mailing Address - Fax:
Practice Address - Street 1:218 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3628
Practice Address - Country:US
Practice Address - Phone:770-386-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN098665164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse