Provider Demographics
NPI:1982202206
Name:CHARLES, SAMANTHA R (DNP-C)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:R
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-0990
Mailing Address - Fax:312-472-5270
Practice Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-472-5270
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner