Provider Demographics
NPI:1942637988
Name:LANEZ, CHARISMA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARISMA ANN
Middle Name:
Last Name:LANEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 WILLOW BROOK RD STE 9
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5922
Mailing Address - Country:US
Mailing Address - Phone:732-462-9622
Mailing Address - Fax:
Practice Address - Street 1:161 BARTLEY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-1241
Practice Address - Country:US
Practice Address - Phone:732-363-6140
Practice Address - Fax:732-363-6196
Is Sole Proprietor?:No
Enumeration Date:2013-10-06
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB09522800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program