Provider Demographics
NPI:1245634195
Name:STAFF, CHARLENE SHARON
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:SHARON
Last Name:STAFF
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 1:22681 WOODWARD AVE UNIT 20042
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-7001
Mailing Address - Country:US
Mailing Address - Phone:248-971-9178
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:STE 260
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067
Practice Address - Country:US
Practice Address - Phone:248-971-9178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant