Provider Demographics
NPI:1134375629
Name:PHERSON, CHARLENE R (FNP)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:R
Last Name:PHERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:G
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:DEPT. OF INTERNAL MEDICINE/CARDIOLOGY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298
Practice Address - Country:US
Practice Address - Phone:804-828-9700
Practice Address - Fax:804-828-7710
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223052989OtherTAX ID#
NJ157614Medicare PIN
NJ0255556Medicaid