Provider Demographics
NPI:1548580509
Name:DRAKE, CHARLOTTE R (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:R
Last Name:DRAKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7163 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1904
Mailing Address - Country:US
Mailing Address - Phone:662-895-3700
Mailing Address - Fax:662-895-4886
Practice Address - Street 1:1264 WESLEY DR
Practice Address - Street 2:SUITE 501
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6400
Practice Address - Country:US
Practice Address - Phone:901-346-1800
Practice Address - Fax:901-346-0043
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867991363LF0000X
TN18717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01685008Medicaid
MSMD2458455OtherDEA
MS01685008Medicaid