Provider Demographics
NPI:1710235718
Name:CHARLES, DEDRA LEANN (LPN)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:LEANN
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 1:1004 SUGAR CAMP JACKSON FORK RD
Mailing Address - Street 2:P.O. BOX 101
Mailing Address - City:SOUTH WEBSTER
Mailing Address - State:OH
Mailing Address - Zip Code:45682-9033
Mailing Address - Country:US
Mailing Address - Phone:740-285-0326
Mailing Address - Fax:740-778-4016
Practice Address - Street 1:1004 SUGAR CAMP JACKSON FORK RD
Practice Address - Street 2:
Practice Address - City:SOUTH WEBSTER
Practice Address - State:OH
Practice Address - Zip Code:45682-9033
Practice Address - Country:US
Practice Address - Phone:740-285-0326
Practice Address - Fax:740-778-4016
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH120152164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse