Provider Demographics
NPI:1699211086
Name:CHARLES, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10108 FREESIAN WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8030
Mailing Address - Country:US
Mailing Address - Phone:561-714-7858
Mailing Address - Fax:561-549-1207
Practice Address - Street 1:10108 FREESIAN WAY
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8030
Practice Address - Country:US
Practice Address - Phone:561-714-7858
Practice Address - Fax:561-549-1207
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9309010163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse