Provider Demographics
NPI:1679004642
Name:CHARLES, HERMIONE
Entity Type:Individual
Prefix:
First Name:HERMIONE
Middle Name:
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 1:4949 LIBERTY LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 LIBERTY LN
Practice Address - Street 2:SUITE 210
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9014
Practice Address - Country:US
Practice Address - Phone:484-560-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN264701164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102888687Medicaid