Provider Demographics
NPI:1982943254
Name:CHARLES, KIMBERLY NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 MARCUS AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1033
Mailing Address - Country:US
Mailing Address - Phone:516-403-1550
Mailing Address - Fax:
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-403-1550
Practice Address - Fax:516-403-1551
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily