Provider Demographics
NPI:1992116149
Name:JEAN CHARLES, EVENA
Entity type:Individual
Prefix:MRS
First Name:EVENA
Middle Name:
Last Name:JEAN CHARLES
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 1:1551 DOZIER CIR SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6535
Mailing Address - Country:US
Mailing Address - Phone:321-723-8383
Mailing Address - Fax:
Practice Address - Street 1:1551 DOZIER CIR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6535
Practice Address - Country:US
Practice Address - Phone:321-723-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6906630Medicaid