Provider Demographics
NPI:1396171385
Name:CHARLES, EDNER (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:EDNER
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2806
Mailing Address - Country:US
Mailing Address - Phone:240-419-2412
Mailing Address - Fax:
Practice Address - Street 1:2670 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2806
Practice Address - Country:US
Practice Address - Phone:240-419-2412
Practice Address - Fax:240-419-2495
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18462363LP0808X
MDAC001257363LP0808X
MDR229551363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health