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General NPI Number Information
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NPI Number | 1154534626
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Entity Type | Individual
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Provider Name | JACQUETTA ANTOINETTE CHARLES-MORRIS PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 04/30/2010
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Provider Practice Location Address
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Address Line | 5601 LOCH RAVEN BLVD
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City | BALTIMORE
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State | MD
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Zip | 21239
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Country | US
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Telephone | 410-532-4396
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Fax |
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Provider Business Mailing Address
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Address Line | 906 SCOTTS HILL DRIVE
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City | PIKESVILLE
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State | MD
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Zip | 21208
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Country | US
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Telephone | 410-415-5056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C0003251
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License Number State | MD
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