Provider Demographics
NPI:1649695974
Name:HARTLEY, CHARLENE THERESA
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:THERESA
Last Name:HARTLEY
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 1:1 GOODALL AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4617
Mailing Address - Country:US
Mailing Address - Phone:386-258-5562
Mailing Address - Fax:386-238-5678
Practice Address - Street 1:425 DAYTONA AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-3721
Practice Address - Country:US
Practice Address - Phone:386-258-8291
Practice Address - Fax:386-258-8291
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALF10338172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142002000Medicaid