Healthcare Provider Details

I. General information

NPI: 1104528462
Provider Name (Legal Business Name): KARISSA LENA MARIA CHARLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 RENEE DR
MYRTLE BEACH SC
29579-4109
US

IV. Provider business mailing address

3725 RENEE DR
MYRTLE BEACH SC
29579-4109
US

V. Phone/Fax

Practice location:
  • Phone: 843-350-1124
  • Fax: 877-452-8854
Mailing address:
  • Phone: 843-350-1124
  • Fax: 877-452-8854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number98057
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: