Healthcare Provider Details

I. General information

NPI: 1982943254
Provider Name (Legal Business Name): KIMBERLY NICOLE CHARLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 MARCUS AVE SUITE 116
LAKE SUCCESS NY
11042
US

IV. Provider business mailing address

1999 MARCUS AVE SUITE 116
NEW HYDE PARK NY
11042-1033
US

V. Phone/Fax

Practice location:
  • Phone: 516-403-1550
  • Fax: 516-403-1551
Mailing address:
  • Phone: 516-403-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: