Provider Demographics
NPI:1790047926
Name:MADDIX, CHARLES B (APRN, MSN, PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:B
Last Name:MADDIX
Suffix:
Gender:M
Credentials:APRN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3547 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5309
Mailing Address - Country:US
Mailing Address - Phone:904-409-7778
Mailing Address - Fax:
Practice Address - Street 1:3547 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5309
Practice Address - Country:US
Practice Address - Phone:904-877-1100
Practice Address - Fax:904-877-1200
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN91731132084A0401X, 2084P0804X, 2084P0805X, 261QH0100X, 363LP0808X, 363LP0808X
FL9173113363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner