Healthcare Provider Details

I. General information

NPI: 1699119354
Provider Name (Legal Business Name): STEPHANIE CHARLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 BROADWAY FL 2
NEW YORK NY
10025-7846
US

IV. Provider business mailing address

2875 BROADWAY FL 2MD
NEW YORK NY
10025-7846
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-1600
  • Fax:
Mailing address:
  • Phone: 212-523-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number265577
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number329910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: