Provider Demographics
NPI:1669844940
Name:CHARLESTON, KYONNA
Entity Type:Individual
Prefix:
First Name:KYONNA
Middle Name:
Last Name:CHARLESTON
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 1:6565 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-4565
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129381363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner