Provider Demographics
NPI:1144868886
Name:BLACK, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 RAYNOLDS PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 ATLANTIC ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3702
Practice Address - Country:US
Practice Address - Phone:202-306-5893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant