Provider Demographics
NPI:1861964652
Name:MCCOLLUM, CHARLOTTE (LVN,LPN)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:LVN,LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 TUNDRA DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2586
Mailing Address - Country:US
Mailing Address - Phone:904-565-6035
Mailing Address - Fax:
Practice Address - Street 1:635 TUNDRA DR
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2586
Practice Address - Country:US
Practice Address - Phone:904-565-6035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5195601164W00000X
TX337622164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5195601OtherSTATE OF FL DEPT. OF HEALTH
TX337622OtherTEXAS BOARD OF NURSING