Provider Demographics
NPI:1205025137
Name:BREEDLOVE, CHARMAINE DELORES (LVN/LPN)
Entity Type:Individual
Prefix:MS
First Name:CHARMAINE
Middle Name:DELORES
Last Name:BREEDLOVE
Suffix:
Gender:F
Credentials:LVN/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 MUIR RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6067
Mailing Address - Country:US
Mailing Address - Phone:209-524-9022
Mailing Address - Fax:
Practice Address - Street 1:1301 RICHLAND AVE APT 345
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-5023
Practice Address - Country:US
Practice Address - Phone:209-538-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN212774164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse