Provider Demographics
NPI:1528103959
Name:MARK, CHARLENE THERESA (MSN, FNP, BC)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:THERESA
Last Name:MARK
Suffix:
Gender:F
Credentials:MSN, FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1191
Mailing Address - Country:US
Mailing Address - Phone:313-378-2518
Mailing Address - Fax:
Practice Address - Street 1:3031 W GRAND BLVD STE 800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3141
Practice Address - Country:US
Practice Address - Phone:313-916-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704138698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily