Provider Demographics
NPI:1427034644
Name:MOYER, CHARLENE (NP)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:MOYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 WADSWORTH RD.
Mailing Address - Street 2:SUITE 402
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281
Mailing Address - Country:US
Mailing Address - Phone:330-331-7207
Mailing Address - Fax:330-331-7587
Practice Address - Street 1:195 WADSWORTH RD.
Practice Address - Street 2:SUITE 402
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281
Practice Address - Country:US
Practice Address - Phone:330-331-7207
Practice Address - Fax:330-331-7587
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05255363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH221456Medicaid
OH2221456Medicaid
OHMONP05004Medicare PIN
OH2221456Medicaid