Provider Demographics
NPI:1104138213
Name:MITCHELL-PERRY, CHARLISSA
Entity type:Individual
Prefix:
First Name:CHARLISSA
Middle Name:
Last Name:MITCHELL-PERRY
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 1:3210 OSUNA WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2787
Mailing Address - Country:US
Mailing Address - Phone:916-568-0700
Mailing Address - Fax:
Practice Address - Street 1:3210 OSUNA WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-2787
Practice Address - Country:US
Practice Address - Phone:916-568-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
347C00000X
CA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)