Provider Demographics
NPI:1316434368
Name:POLYDORE, CHARITY RAQUEL (BSN)
Entity type:Individual
Prefix:MRS
First Name:CHARITY
Middle Name:RAQUEL
Last Name:POLYDORE
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:MRS
Other - First Name:CHARITY
Other - Middle Name:RAQUEL
Other - Last Name:GORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN
Mailing Address - Street 1:1700 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7529
Mailing Address - Country:US
Mailing Address - Phone:717-272-6621
Mailing Address - Fax:717-228-6120
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-6120
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1109090163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse