Provider Demographics
NPI:1417590613
Name:CHARLES, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FOXBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:02035-1496
Mailing Address - Country:US
Mailing Address - Phone:774-215-5579
Mailing Address - Fax:
Practice Address - Street 1:113 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FOXBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:02035-1496
Practice Address - Country:US
Practice Address - Phone:774-215-5579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2263627363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology