Provider Demographics
NPI:1164686788
Name:CHARLES, ANTONIA
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:CHARLES
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 1:539 ATLANTIC AVE # 170619
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1913
Mailing Address - Country:US
Mailing Address - Phone:347-249-3620
Mailing Address - Fax:
Practice Address - Street 1:539 ATLANTIC AVE # 170619
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1913
Practice Address - Country:US
Practice Address - Phone:347-249-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-13
Last Update Date:2022-10-12
Deactivation Date:2011-05-27
Deactivation Code:
Reactivation Date:2022-06-30
Provider Licenses
StateLicense IDTaxonomies
NY893900261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health