Provider Demographics
NPI:1154008100
Name:CHARLES, NICOLE DIANE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2302
Mailing Address - Country:US
Mailing Address - Phone:313-331-3435
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-331-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist