Provider Demographics
NPI:1376048348
Name:CHARLES, MARIE FAYETTE (CRNP-FNP-PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:FAYETTE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:CRNP-FNP-PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3231
Mailing Address - Country:US
Mailing Address - Phone:240-419-2412
Mailing Address - Fax:240-366-5753
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3231
Practice Address - Country:US
Practice Address - Phone:240-419-2412
Practice Address - Fax:240-366-5753
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180406363LF0000X, 363LP0808X
MDR221196363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD911012700Medicaid
VA601507691Medicaid