Provider Demographics
NPI:1023301702
Name:CHARLES, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:CHARLES
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 1:121 BREEZE AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5903
Mailing Address - Country:US
Mailing Address - Phone:718-217-1002
Mailing Address - Fax:516-539-2121
Practice Address - Street 1:550 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4445
Practice Address - Country:US
Practice Address - Phone:718-217-1002
Practice Address - Fax:516-539-2121
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270564164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse