Provider Demographics
NPI:1518336080
Name:WALTON WINDHAM, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WALTON WINDHAM
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 1:17515 W 9 MILE RD
Mailing Address - Street 2:STE. 375
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17515 W 9 MILE RD
Practice Address - Street 2:375
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4403
Practice Address - Country:US
Practice Address - Phone:248-559-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210421363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology