Provider Demographics
NPI:1447745328
Name:CHARLES, URSLINE
Entity Type:Individual
Prefix:
First Name:URSLINE
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 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-282-4051
Mailing Address - Fax:562-741-4479
Practice Address - Street 1:2868 PROSPECT PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6065
Practice Address - Country:US
Practice Address - Phone:916-388-3532
Practice Address - Fax:916-388-3533
Is Sole Proprietor?:No
Enumeration Date:2018-06-24
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily