Provider Demographics
NPI:1689900540
Name:CHARLES, MARTHA A (LPN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 COLLINSTON RD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-8703
Mailing Address - Country:US
Mailing Address - Phone:318-351-0850
Mailing Address - Fax:318-239-3704
Practice Address - Street 1:9211 COLLINSTON RD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-8703
Practice Address - Country:US
Practice Address - Phone:318-351-0850
Practice Address - Fax:318-239-3704
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA870290164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse