Provider Demographics
NPI:1033683552
Name:CHARLOT, CARLISE YVETTE (COSMETOLOGY)
Entity Type:Individual
Prefix:
First Name:CARLISE
Middle Name:YVETTE
Last Name:CHARLOT
Suffix:
Gender:F
Credentials:COSMETOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 WINDY WILLOWS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5957
Mailing Address - Country:US
Mailing Address - Phone:904-716-9432
Mailing Address - Fax:
Practice Address - Street 1:1289 WINDY WILLOWS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5957
Practice Address - Country:US
Practice Address - Phone:904-716-9432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL02197441744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty