Provider Demographics
NPI:1710609003
Name:LEON, CHARISE MARIE
Entity Type:Individual
Prefix:MS
First Name:CHARISE
Middle Name:MARIE
Last Name:LEON
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 1:1701 SW 16TH AVE BLDG B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1153
Mailing Address - Country:US
Mailing Address - Phone:352-294-8588
Mailing Address - Fax:
Practice Address - Street 1:1701 SW 16TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1153
Practice Address - Country:US
Practice Address - Phone:352-294-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690540496Medicaid