Provider Demographics
NPI:1770143430
Name:FALCONER, CHARLES DANIEL (MSN, CRNP, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:FALCONER
Suffix:
Gender:M
Credentials:MSN, CRNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 COFFEE RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1582
Mailing Address - Country:US
Mailing Address - Phone:209-524-9401
Mailing Address - Fax:
Practice Address - Street 1:600 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4201
Practice Address - Country:US
Practice Address - Phone:209-524-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH111054-23363LP0808X
CA95410984163W00000X
NH111054-21163W00000X
CA95034112363LP0808X
PASP021192363LP0808X
PARN694705163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse