Provider Demographics
NPI:1265018865
Name:FABIEN CHARLES, KETHLIE
Entity Type:Individual
Prefix:
First Name:KETHLIE
Middle Name:
Last Name:FABIEN 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 1:5700 LAKE WORTH RD STE 106
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3213
Mailing Address - Country:US
Mailing Address - Phone:561-439-3991
Mailing Address - Fax:561-439-3993
Practice Address - Street 1:5700 LAKE WORTH RD STE 106
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3213
Practice Address - Country:US
Practice Address - Phone:561-439-3991
Practice Address - Fax:561-439-3993
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities