Provider Demographics
NPI:1366866329
Name:MOORE, CHARLENE (RN)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13309 OAKVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-3951
Mailing Address - Country:US
Mailing Address - Phone:216-266-7318
Mailing Address - Fax:
Practice Address - Street 1:5676 BROADVIEW RD
Practice Address - Street 2:APT 523
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44134-1635
Practice Address - Country:US
Practice Address - Phone:216-551-2845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN152204164W00000X
OH520052163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No164W00000XNursing Service ProvidersLicensed Practical Nurse