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General NPI Number Information
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NPI Number | 1962492975
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Entity Type | Individual
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Provider Name | CHARLOTTE FLORENCE NIELSEN O.D.
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Gender | Female
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Dates
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Enumeration Date | 10/21/2005
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 1120 E WASHINGTON ST
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City | GRAYSLAKE
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State | IL
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Zip | 60030-7960
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Country | US
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Telephone | 847-223-2000
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Fax | 847-223-9400
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Provider Business Mailing Address
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Address Line | 1120 E WASHINGTON ST
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City | GRAYSLAKE
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State | IL
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Zip | 60030-7960
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Country | US
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Telephone | 847-223-2000
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Fax | 847-223-9400
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046008590
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License Number State | IL
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