Provider Demographics
NPI:1376581751
Name:WIDICK, CHARLOTTE IRENE (ENP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:IRENE
Last Name:WIDICK
Suffix:
Gender:F
Credentials:ENP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 S HIGHWAY 281
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:TX
Mailing Address - Zip Code:78606
Mailing Address - Country:US
Mailing Address - Phone:830-833-0510
Mailing Address - Fax:
Practice Address - Street 1:322 COLEMAN ST
Practice Address - Street 2:
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661-2358
Practice Address - Country:US
Practice Address - Phone:254-803-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX575896363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117953308Medicaid
TXS58286Medicare UPIN
TX117953308Medicaid
TX8G1679Medicare PIN