Provider Demographics
NPI:1144091240
Name:FILLMORE, CHARITY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:LEE
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MONK LN
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-4448
Mailing Address - Country:US
Mailing Address - Phone:843-345-9061
Mailing Address - Fax:
Practice Address - Street 1:1670 DRY DOCK AVE BLDG 10
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-2114
Practice Address - Country:US
Practice Address - Phone:843-747-3526
Practice Address - Fax:843-747-3527
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant