Healthcare Provider Details

I. General information

NPI: 1710235718
Provider Name (Legal Business Name): DEDRA LEANN CHARLES LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2012
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 SUGAR CAMP JACKSON FORK RD
SOUTH WEBSTER OH
45682-9033
US

IV. Provider business mailing address

1004 SUGAR CAMP JACKSON FORK RD P.O. BOX 101
SOUTH WEBSTER OH
45682-9033
US

V. Phone/Fax

Practice location:
  • Phone: 740-285-0326
  • Fax: 740-778-4016
Mailing address:
  • Phone: 740-285-0326
  • Fax: 740-778-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number120152
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: