Provider Demographics
NPI:1255112280
Name:CHARLES, ANTOINETTE NINA
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:NINA
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 1:1324 SAINT JOHNS PL APT 4A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-6705
Mailing Address - Country:US
Mailing Address - Phone:917-749-4314
Mailing Address - Fax:
Practice Address - Street 1:1324 SAINT JOHNS PL APT 4A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-6705
Practice Address - Country:US
Practice Address - Phone:917-749-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY677481163WA2000X, 163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health