Provider Demographics
NPI:1154900652
Name:IRVING, CHARNELLE
Entity type:Individual
Prefix:
First Name:CHARNELLE
Middle Name:
Last Name:IRVING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARNELLE
Other - Middle Name:L
Other - Last Name:IRVING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS IRVING
Mailing Address - Street 1:21300 CLARITA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2466
Mailing Address - Country:US
Mailing Address - Phone:313-870-8095
Mailing Address - Fax:
Practice Address - Street 1:21300 CLARITA STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219
Practice Address - Country:UM
Practice Address - Phone:313-870-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MII615115546417343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)