Provider Demographics
NPI:1861666729
Name:ANDERSON, CHARLENE MARY
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MARY
Last Name:ANDERSON
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 1:447 N EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1403
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:626-577-8978
Practice Address - Street 1:200 E WASHINGTON AVE
Practice Address - Street 2:#100
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-1806
Practice Address - Country:US
Practice Address - Phone:760-737-8642
Practice Address - Fax:760-737-8918
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461728163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse