Provider Demographics
NPI:1073941670
Name:DOUGLAS, CHARLOTTE FAY (NP)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:FAY
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1356
Mailing Address - Country:US
Mailing Address - Phone:815-432-3507
Mailing Address - Fax:
Practice Address - Street 1:200 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1356
Practice Address - Country:US
Practice Address - Phone:815-432-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily