Provider Demographics
NPI:1528617081
Name:CHARLES, ASTRUDE
Entity type:Individual
Prefix:
First Name:ASTRUDE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 AZALEA CIR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-4474
Mailing Address - Country:US
Mailing Address - Phone:561-452-4796
Mailing Address - Fax:561-469-1196
Practice Address - Street 1:5701 AZALEA CIR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-4474
Practice Address - Country:US
Practice Address - Phone:561-452-4796
Practice Address - Fax:561-469-1196
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9496468163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL19000172356Medicaid