Provider Demographics
NPI:1669747069
Name:CHARLES, ANCIL DOMINIC (LPN)
Entity type:Individual
Prefix:MR
First Name:ANCIL
Middle Name:DOMINIC
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13952 225TH ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2741
Mailing Address - Country:US
Mailing Address - Phone:718-877-5718
Mailing Address - Fax:718-276-6061
Practice Address - Street 1:13952 225TH ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2741
Practice Address - Country:US
Practice Address - Phone:718-877-5718
Practice Address - Fax:718-276-6061
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247286-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse