Provider Demographics
NPI:1730176629
Name:ANDERSON, CHARLENE M (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 18TH STREET
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5622
Mailing Address - Country:US
Mailing Address - Phone:610-628-8372
Mailing Address - Fax:610-628-8648
Practice Address - Street 1:400 N 17TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5052
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN266339L163W00000X
PA040491367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0063046OtherFIRST PRIORITY
PA0063046OtherHIGHMARK
PA0063046OtherKHP CENTRAL
PA9699193OtherAETNA
PA0070312970003Medicaid
PA01484202OtherCAPITAL ADVANTAGE
PA0718259000OtherINDEP. BLUE CROSS
PA11766001OtherCAQH
PA1585085OtherGATEWAY
PA82832OtherGEISINGER
PA11766001OtherCAQH
PA063046QCYMedicare PIN
PA0063046OtherKHP CENTRAL