Healthcare Provider Details

I. General information

NPI: 1073084877
Provider Name (Legal Business Name): CHARISSE HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BELLEVUE RD STE 2
DUBLIN GA
31021-2885
US

IV. Provider business mailing address

2400 BELLEVUE RD STE 2
DUBLIN GA
31021-2885
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-8580
  • Fax:
Mailing address:
  • Phone: 478-272-8580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN216446
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: