1730519851 NPI number — MRS. CHARMAINE MICHELLE STETSON OWNER

Table of content: MRS. CHARMAINE MICHELLE STETSON OWNER (NPI 1730519851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730519851 NPI number — MRS. CHARMAINE MICHELLE STETSON OWNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STETSON
Provider First Name:
CHARMAINE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OWNER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOODLEY
Provider Other First Name:
CHARMAINE
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730519851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 ANGEL HOLLOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSENBERG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77469-2283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
729-161-9309
Provider Business Mailing Address Fax Number:
972-584-1708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 ANGEL HOLLOW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSENBERG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77469-2283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-916-1930
Provider Business Practice Location Address Fax Number:
972-584-1708
Provider Enumeration Date:
11/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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