Provider Demographics
NPI:1265874218
Name:PENDLETON, CHARLOTTE JEAN (LMP)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:JEAN
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 QUEEN PALM DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-6624
Mailing Address - Country:US
Mailing Address - Phone:386-402-6555
Mailing Address - Fax:
Practice Address - Street 1:1420 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-4087
Practice Address - Country:US
Practice Address - Phone:206-682-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA10264225700000X
FLMA46099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist