Provider Demographics
NPI:1548010689
Name:ALLEN, CHARISSA
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9617
Mailing Address - Country:US
Mailing Address - Phone:315-414-6748
Mailing Address - Fax:
Practice Address - Street 1:3307 LYSANDER RD
Practice Address - Street 2:
Practice Address - City:CATO
Practice Address - State:NY
Practice Address - Zip Code:13033-8779
Practice Address - Country:US
Practice Address - Phone:315-414-6748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY770729163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health