Provider Demographics
NPI:1326300294
Name:SMITH, CHARLENE MARTIN (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:MARTIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4477
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:860 OMNI BLVD STE 110
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4430
Practice Address - Country:US
Practice Address - Phone:757-232-8769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170046363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541188948OtherEMPLOYER'S TAX ID