Provider Demographics
NPI:1295196194
Name:CHARLIE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:CHARLIE
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 1:155 HOSPITAL DR STE 205
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2852
Mailing Address - Country:US
Mailing Address - Phone:374-841-0913
Mailing Address - Fax:337-484-1092
Practice Address - Street 1:155 HOSPITAL DR STE 205
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-484-1091
Practice Address - Fax:337-484-1092
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA307726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program