Provider Demographics
NPI:1417370065
Name:CAPULONG, CHARLOTTE (NP-C)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:CAPULONG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0457
Mailing Address - Country:US
Mailing Address - Phone:909-971-9334
Mailing Address - Fax:909-971-9654
Practice Address - Street 1:130 WEST ROUTE 66
Practice Address - Street 2:STE 326
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6252
Practice Address - Country:US
Practice Address - Phone:626-963-8588
Practice Address - Fax:626-963-8578
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP23824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP23824OtherSTATE LICENSE