Provider Demographics
NPI:1528592243
Name:CHARLY, BERTA MARIAM (FNP-C)
Entity Type:Individual
Prefix:
First Name:BERTA
Middle Name:MARIAM
Last Name:CHARLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 VANDER ROCK DR.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095
Mailing Address - Country:US
Mailing Address - Phone:281-455-0093
Mailing Address - Fax:
Practice Address - Street 1:9411 VANDER ROCK DR.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095
Practice Address - Country:US
Practice Address - Phone:281-455-0093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily