Healthcare Provider Details

I. General information

NPI: 1710353842
Provider Name (Legal Business Name): CHARMAINE MARY SULAICA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S CESAR CHAVEZ AVE
CRYSTAL CITY TX
78839-4200
US

IV. Provider business mailing address

308 S CESAR CHAVEZ AVE
CRYSTAL CITY TX
78839-4200
US

V. Phone/Fax

Practice location:
  • Phone: 830-374-2301
  • Fax: 830-374-9368
Mailing address:
  • Phone: 317-266-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71007931A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP128590
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: