Provider Demographics
NPI:1790509297
Name:BLISS, CHARMAINE L (RN)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:L
Last Name:BLISS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CHARMAINE
Other - Middle Name:
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:636 GRIFFIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANTVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30220-2003
Mailing Address - Country:US
Mailing Address - Phone:815-394-0685
Mailing Address - Fax:
Practice Address - Street 1:122 GORDON COMMERCIAL DR STE C
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5754
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:706-845-4367
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240982163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse