Healthcare Provider Details

I. General information

NPI: 1306078357
Provider Name (Legal Business Name): CHARLES ANTHONY ANCRUM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 09/06/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RIVERSTONE DR
COVINGTON GA
30014-5027
US

IV. Provider business mailing address

20 RIVERSTONE DR
COVINGTON GA
30014-5027
US

V. Phone/Fax

Practice location:
  • Phone: 404-510-5027
  • Fax:
Mailing address:
  • Phone: 404-510-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number622351
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number622351-01
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number622351-01
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number622351-01
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number622351-01
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: