Provider Demographics
NPI:1306378294
Name:SOUTHERLAND, CHARLETTE
Entity Type:Individual
Prefix:
First Name:CHARLETTE
Middle Name:
Last Name:SOUTHERLAND
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 1:1511 DECEMBER DR APT 404
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3619
Mailing Address - Country:US
Mailing Address - Phone:240-705-0357
Mailing Address - Fax:
Practice Address - Street 1:209 BRYANT ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1119
Practice Address - Country:US
Practice Address - Phone:202-971-5364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant