Provider Demographics
NPI:1407176381
Name:CHARLES, PHILOMENE MIANTHA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PHILOMENE
Middle Name:MIANTHA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 203RD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3549
Mailing Address - Country:US
Mailing Address - Phone:718-977-0049
Mailing Address - Fax:
Practice Address - Street 1:11820 203RD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3549
Practice Address - Country:US
Practice Address - Phone:718-977-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289345-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse