Provider Demographics
NPI:1932209939
Name:DAVIS, CHARLENE H (NP)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:CHARLENE
Other - Middle Name:M
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 1601
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-4842
Practice Address - Fax:317-948-0126
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28090894363LP0200X
IN71000286363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200277570Medicaid
Q17148Medicare UPIN
IN200277570Medicaid