Provider Demographics
NPI:1083873202
Name:COLEMAN, CHARLENE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 HAZELWOOD TER
Mailing Address - Street 2:P.O. BOX 90553
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-5220
Mailing Address - Country:US
Mailing Address - Phone:585-360-4636
Mailing Address - Fax:
Practice Address - Street 1:267 HAZELWOOD TER
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-5220
Practice Address - Country:US
Practice Address - Phone:585-360-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282243-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02748974Medicaid