Provider Demographics
NPI:1619730173
Name:CHARLES, BLANCA (RN)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11479 S 264TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-6750
Mailing Address - Country:US
Mailing Address - Phone:918-407-4999
Mailing Address - Fax:
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2536
Practice Address - Country:US
Practice Address - Phone:918-660-3071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK98202163WC0400X
OK21420039163WD0400X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator