Provider Demographics
NPI:1801511597
Name:NUGENT, CHARLIE JOE (LCP, CCP)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JOE
Last Name:NUGENT
Suffix:
Gender:M
Credentials:LCP, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 SANGO RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-7307
Mailing Address - Country:US
Mailing Address - Phone:931-624-0020
Mailing Address - Fax:
Practice Address - Street 1:1640 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1538
Practice Address - Country:US
Practice Address - Phone:954-939-0274
Practice Address - Fax:954-337-0760
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN167246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist