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General NPI Number Information
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NPI Number | 1942502992
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Entity Type | Individual
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Provider Name | CHARLA MARIE PHOENIX PAC
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Gender | Female
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Dates
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Enumeration Date | 11/24/2010
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 200 HYGEIA DR STE 1420
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City | NEWARK
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State | DE
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Zip | 19713-2049
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Country | US
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Telephone | 302-623-3017
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Fax | 302-266-9962
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Provider Business Mailing Address
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Address Line | 620 STANTON CHRISTIANA RD SUITE 302
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City | NEWARK
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State | DE
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Zip | 19713-2133
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Country | US
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Telephone | 302-892-9400
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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 | C0009749
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License Number State | MD
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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 | C5-0000735
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License Number State | DE
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