Provider Demographics
NPI:1932216264
Name:CHARBONNEAU, VICKI L (NP, CNM)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-739-3474
Mailing Address - Fax:805-739-3982
Practice Address - Street 1:35 CASA STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1890
Practice Address - Country:US
Practice Address - Phone:805-786-4111
Practice Address - Fax:805-543-6357
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner