Provider Demographics
NPI:1598188179
Name:CHARLES, MIREILLE (NP-C)
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 WOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1235
Mailing Address - Country:US
Mailing Address - Phone:516-208-7094
Mailing Address - Fax:516-208-7094
Practice Address - Street 1:1 PENN PLZ
Practice Address - Street 2:SUITE 725
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0002
Practice Address - Country:US
Practice Address - Phone:612-655-5942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-01
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306590363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health