Provider Demographics
NPI:1063042836
Name:CHARLES, SELANDE GESSE (NP)
Entity type:Individual
Prefix:MRS
First Name:SELANDE
Middle Name:GESSE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SWEETLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-1731
Mailing Address - Country:US
Mailing Address - Phone:973-715-0066
Mailing Address - Fax:908-686-1595
Practice Address - Street 1:530 SWEETLAND AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-1731
Practice Address - Country:US
Practice Address - Phone:973-715-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01008200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty