Healthcare Provider Details

I. General information

NPI: 1861181323
Provider Name (Legal Business Name): CHARISSA HARRISTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 TINKER RD
BALTIMORE MD
21220-3799
US

IV. Provider business mailing address

612 TINKER RD
BALTIMORE MD
21220-3799
US

V. Phone/Fax

Practice location:
  • Phone: 667-220-6406
  • Fax: 443-817-0771
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR128308
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR128308
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163WD1100X
TaxonomyPeritoneal Dialysis Registered Nurse
License NumberR128308
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR128308
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberR128308
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberR128308
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR128308
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberR128308
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberR128308
License Number StateMD
# 10
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR128308
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: