Healthcare Provider Details

I. General information

NPI: 1972843126
Provider Name (Legal Business Name): CHARLEITTE PHILLIPS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 FULTON MILL RD
MACON GA
31206-5125
US

IV. Provider business mailing address

4785 RAPIDS CIR NW
ACWORTH GA
30102-7993
US

V. Phone/Fax

Practice location:
  • Phone: 478-803-7600
  • Fax:
Mailing address:
  • Phone: 248-778-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN250274
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704131775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: