Healthcare Provider Details

I. General information

NPI: 1023335833
Provider Name (Legal Business Name): CHARLENE L MADDOX RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 TOWER CIR
SOMERSET KY
42503-3479
US

IV. Provider business mailing address

4330 LEBANON RD
DANVILLE KY
40422-9626
US

V. Phone/Fax

Practice location:
  • Phone: 606-676-0786
  • Fax: 606-451-0446
Mailing address:
  • Phone: 606-676-0786
  • Fax: 606-451-0446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number1045879
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: