Healthcare Provider Details

I. General information

NPI: 1710576707
Provider Name (Legal Business Name): CHARLYN ANNISE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 NAPIER AVE STE B
MACON GA
31204-3872
US

IV. Provider business mailing address

2865 CHURCHILL ST
MACON GA
31204-5260
US

V. Phone/Fax

Practice location:
  • Phone: 470-269-2109
  • Fax:
Mailing address:
  • Phone: 470-269-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: