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General NPI Number Information
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NPI Number | 1649695974
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Entity Type | Individual
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Provider Name | CHARLENE THERESA HARTLEY
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Gender | Female
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Dates
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Enumeration Date | 02/24/2014
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Last Update Date | 02/24/2014
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Provider Practice Location Address
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Address Line | 425 DAYTONA AVE
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City | HOLLY HILL
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State | FL
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Zip | 32117-3721
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Country | US
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Telephone | 386-258-8291
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Fax | 386-258-8291
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Provider Business Mailing Address
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Address Line | 1 GOODALL AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32118-4617
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Country | US
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Telephone | 386-258-5562
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Fax | 386-238-5678
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | ALF10338
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License Number State | FL
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