Provider Demographics
NPI:1811553480
Name:LOUIS-CHARLES, MANDALY CLAUDE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MANDALY
Middle Name:CLAUDE
Last Name:LOUIS-CHARLES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 NIGHTHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-4132
Mailing Address - Country:US
Mailing Address - Phone:727-504-6986
Mailing Address - Fax:
Practice Address - Street 1:12470 TELECOM DR STE 300W
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-871-8183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty