MEDICARE: CHARLAINE CONGER FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN262353	GA

General Provider Information

NPI Number	:	1093326159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLAINE CONGER FNP-C

Provider Business Mailing Address
First Line	:	105 LAKE MURRAY DR
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-8639
Country	:	US
Telephone Number	:	803-292-9250
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 LAKE MURRAY DR
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-8639
Country	:	US
Telephone Number	:	803-292-9250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	08/12/2020

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