Provider Demographics
NPI:1275097800
Name:CHARLESTON, ANTOINETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:CHARLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:CHARLESTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:136 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-4302
Mailing Address - Country:US
Mailing Address - Phone:337-693-9445
Mailing Address - Fax:
Practice Address - Street 1:136 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4302
Practice Address - Country:US
Practice Address - Phone:337-693-9445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA12101972OtherPRIVATE