Healthcare Provider Details

I. General information

NPI: 1710879986
Provider Name (Legal Business Name): JOHANE CHARLESTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321B GREENVILLE ST
LAGRANGE GA
30241-3231
US

IV. Provider business mailing address

800 GALLERIA PKWY SE UNIT 736
ATLANTA GA
30339-6019
US

V. Phone/Fax

Practice location:
  • Phone: 678-810-1955
  • Fax:
Mailing address:
  • Phone: 678-230-1284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN270338
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: