Provider Demographics
NPI:1104153006
Name:MIDDLETON, CHRISSIE
Entity type:Individual
Prefix:
First Name:CHRISSIE
Middle Name:
Last Name:MIDDLETON
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:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29602-0287
Mailing Address - Country:US
Mailing Address - Phone:864-729-8330
Mailing Address - Fax:
Practice Address - Street 1:4109 E NORTH ST STE 300C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6227
Practice Address - Country:US
Practice Address - Phone:864-409-7041
Practice Address - Fax:864-428-1286
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3964363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily