Provider Demographics
NPI:1720050578
Name:BLAINE, CHARLENE LYDIA (CRT, RCP)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:LYDIA
Last Name:BLAINE
Suffix:
Gender:F
Credentials:CRT, RCP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:343 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-7949
Mailing Address - Country:US
Mailing Address - Phone:919-780-5900
Mailing Address - Fax:919-780-5905
Practice Address - Street 1:343 TECHNOLOGY DR
Practice Address - Street 2:SUITE 1110
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-7949
Practice Address - Country:US
Practice Address - Phone:919-780-5900
Practice Address - Fax:919-780-5905
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-41252278P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary Diagnostics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139EEOtherBLUE SHIELD NC
NC7492701Medicaid
NCA-4125OtherLICENSE
NC2881822Medicare PIN