Provider Demographics
NPI:1932408960
Name:WILLIAMSON, CHARLAINE IDA (NP)
Entity Type:Individual
Prefix:
First Name:CHARLAINE
Middle Name:IDA
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHARLAINE
Other - Middle Name:
Other - Last Name:BADGEROW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:11422 ANZIO CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8500
Mailing Address - Country:US
Mailing Address - Phone:909-996-9903
Mailing Address - Fax:
Practice Address - Street 1:9170 HAVEN AVE STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5416
Practice Address - Country:US
Practice Address - Phone:909-476-8700
Practice Address - Fax:909-987-1400
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily