Provider Demographics
NPI:1639594856
Name:CHARLES, MARIE MALCINE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:MALCINE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 193RD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11721 193RD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3305
Practice Address - Country:US
Practice Address - Phone:718-977-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296604164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse