Provider Demographics
NPI:1346234259
Name:FLORENCE, CHARLES B (ARNP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:FLORENCE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:SUITE 195
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-4263
Practice Address - Fax:502-629-4282
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1092268163W00000X
IN28156953A163W00000X
KY4190P363L00000X
KY3004190363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78017803Medicaid
KY162148OtherSIHO
KY000000883797OtherANTHEM-LAH
KY50076093OtherPASSPORT-LAH
KY1264422Medicare ID - Type Unspecified
KYQ17979Medicare UPIN
IN218440MMedicare ID - Type Unspecified
KY78017803Medicaid