Healthcare Provider Details

I. General information

NPI: 1669073474
Provider Name (Legal Business Name): CHARMAINE A. BYRD DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3469 LAWRENCEVILLE HWY STE 103
TUCKER GA
30084-5889
US

IV. Provider business mailing address

1500 LAKELAND HILLS BLVD
LAKELAND FL
33805-3257
US

V. Phone/Fax

Practice location:
  • Phone: 770-939-6480
  • Fax:
Mailing address:
  • Phone: 321-615-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11010095
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberGAA-NP000627
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: