Provider Demographics
NPI:1689351579
Name:PORTER, CHARLENE CARLETHA (RN)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:CARLETHA
Last Name:PORTER
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 1:114 FORCE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-2531
Mailing Address - Country:US
Mailing Address - Phone:229-291-6050
Mailing Address - Fax:
Practice Address - Street 1:114 FORCE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2531
Practice Address - Country:US
Practice Address - Phone:229-291-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN313322163WH0200X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health