Provider Demographics
NPI:1093960221
Name:CHARLES, NIAMH AIBHLINN (CNM)
Entity Type:Individual
Prefix:
First Name:NIAMH
Middle Name:AIBHLINN
Last Name:CHARLES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LENORE
Other - Middle Name:ADEILLE
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:13160 JERUSALEM HILL RD. NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304
Mailing Address - Country:US
Mailing Address - Phone:503-315-2229
Mailing Address - Fax:503-868-7286
Practice Address - Street 1:13160 JERUSALEM HILL RD. NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304
Practice Address - Country:US
Practice Address - Phone:503-315-2229
Practice Address - Fax:503-868-7286
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850501NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500638900Medicaid
OR213342Medicaid
OR1619915113OtherWATERFALL CLINIC, INC. GROUP NPI
381902Medicare Oscar/Certification