MEDICARE: MR. CHARLES B MADDIX APRN, MSN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	APRN9173113	FL
2	2084P0804X	Child & Adolescent Psychiatry Physician	APRN9173113	FL
3	2084P0805X	Geriatric Psychiatry Physician	APRN9173113	FL
4	261QH0100X	Health Service Clinic/Center	APRN9173113	FL
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN9173113	FL

General Provider Information

NPI Number	:	1790047926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES B MADDIX APRN, MSN, PMHNP-BC

Provider Business Mailing Address
First Line	:	3547 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5309
Country	:	US
Telephone Number	:	904-409-7778
Fax Number	:

Provider Business Practice Location Address
First Line	:	3547 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5309
Country	:	US
Telephone Number	:	904-877-1100
Fax Number	:	904-877-1200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	04/18/2022

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