Healthcare Provider Details

I. General information

NPI: 1548894561
Provider Name (Legal Business Name): CHARNAA DEJEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 CARDINAL ST APT 1332B
NACOGDOCHES TX
75961-4360
US

IV. Provider business mailing address

1464 BOBING DR
LEWISVILLE TX
75067-6045
US

V. Phone/Fax

Practice location:
  • Phone: 469-271-6117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: