Provider Demographics
NPI:1124345160
Name:MILLER, CHARLENE RENE (NP)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:RENE
Last Name:MILLER
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-4021
Mailing Address - Fax:704-384-5601
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4021
Practice Address - Fax:704-384-5601
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004724363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905265Medicaid