Provider Demographics
NPI:1285076208
Name:PERNELL, CHARLIE JR (STNA)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:PERNELL
Suffix:JR
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 ADDISON RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-1535
Mailing Address - Country:US
Mailing Address - Phone:216-254-1938
Mailing Address - Fax:
Practice Address - Street 1:1101 ADDISON RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1535
Practice Address - Country:US
Practice Address - Phone:216-254-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH501039291105374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH501039291105OtherSTNA