Provider Demographics
NPI:1811436348
Name:GRULKE, CHARLOTTE FISCHER
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:FISCHER
Last Name:GRULKE
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 1:1931 TYLER RDG SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3102
Mailing Address - Country:US
Mailing Address - Phone:404-316-0204
Mailing Address - Fax:
Practice Address - Street 1:2520 WINDY HILL RD SE
Practice Address - Street 2:SUITE 104
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8664
Practice Address - Country:US
Practice Address - Phone:678-501-5601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218147363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics