1912341306 NPI number — LORETTA B. CHARLES NURSE PRACTITIONER

Table of content: LORETTA B. CHARLES NURSE PRACTITIONER (NPI 1912341306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912341306 NPI number — LORETTA B. CHARLES NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLES
Provider First Name:
LORETTA
Provider Middle Name:
B.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912341306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
ATT: CVMC FINANCE DEPT
Provider Business Mailing Address City Name:
BARRE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05641-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-485-4161
Provider Business Mailing Address Fax Number:
802-485-4163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 PAINE MOUNTAIN DRIVE
Provider Second Line Business Practice Location Address:
GREEN MOUNTAIN FAMILY PRACTICE
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-485-4161
Provider Business Practice Location Address Fax Number:
802-485-4163
Provider Enumeration Date:
04/29/2013

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: 363LF0000X , with the licence number:  33 337930 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 101.00113985 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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