Provider Demographics
NPI:1477193134
Name:SOUZA, CHARLI MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLI
Middle Name:MARIE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45924 KEDING ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-6022
Mailing Address - Country:US
Mailing Address - Phone:810-887-1046
Mailing Address - Fax:
Practice Address - Street 1:500 KIRTS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4140
Practice Address - Country:US
Practice Address - Phone:248-824-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2019082597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily