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General NPI Number Information
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NPI Number | 1700564846
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Entity Type | Individual
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Provider Name | NESLY ISMENARD CHARLES PA
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Gender | Male
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 09/27/2024
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Provider Practice Location Address
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Address Line | 3822 BROADWAY STE A
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City | FORT MYERS
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State | FL
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Zip | 33901-8148
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Country | US
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Telephone | 239-900-9170
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Fax |
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Provider Business Mailing Address
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Address Line | 1215 SEA PINES WAY
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City | LANTANA
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State | FL
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Zip | 33462-4248
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Country | US
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Telephone | 561-574-5787
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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 | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 21-268
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10014
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License Number State | AZ
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