Healthcare Provider Details

I. General information

NPI: 1487146601
Provider Name (Legal Business Name): CHARLETTE BOWENS KISSI AFAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLETTE BOWENS KISSI AFARE

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 04/11/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARBOR DR
SOUTH SIOUX CITY NE
68776
US

IV. Provider business mailing address

PO BOX 355
SOUTH SIOUX CITY NE
68776-0355
US

V. Phone/Fax

Practice location:
  • Phone: 402-494-3337
  • Fax: 402-494-3356
Mailing address:
  • Phone: 402-494-3337
  • Fax: 402-379-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: