Provider Demographics
NPI:1861181323
Name:HARRISTON, CHARISSA
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:HARRISTON
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 1:612 TINKER RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-3799
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 TINKER RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-3799
Practice Address - Country:US
Practice Address - Phone:667-220-6406
Practice Address - Fax:443-817-0771
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR128308163WC0400X, 163WD0400X, 163WD1100X, 163WH0200X, 163WH0500X, 163WI0500X, 163WW0000X, 163WX0106X, 171M00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator