Provider Demographics
NPI:1275096232
Name:MISSOURI, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MISSOURI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3791
Mailing Address - Country:US
Mailing Address - Phone:408-401-3259
Mailing Address - Fax:
Practice Address - Street 1:1000 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3791
Practice Address - Country:US
Practice Address - Phone:408-401-3259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker