Provider Demographics
NPI:1588058101
Name:TEETER, CHARLENE CORNETT (RN)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:CORNETT
Last Name:TEETER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28506 HENNEPIN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2875
Mailing Address - Country:US
Mailing Address - Phone:734-751-3391
Mailing Address - Fax:248-912-1165
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-912-1165
Practice Address - Fax:248-912-0077
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155629251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health