Provider Demographics
NPI:1629217013
Name:MERTZ, CHARLES (RN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MERTZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 STONERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3418
Mailing Address - Country:US
Mailing Address - Phone:580-762-2997
Mailing Address - Fax:
Practice Address - Street 1:13 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4808
Practice Address - Country:US
Practice Address - Phone:580-765-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0080905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse