Basic Information
| Provider Information | |||||||||
| NPI: | 1144341231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHGAN | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEHGAN | ||||||||
| OtherFirstName: | CHARLOTTE | ||||||||
| OtherMiddleName: | MARSHALL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 579 | ||||||||
| Address2: | |||||||||
| City: | KITTANNING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162010579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245438164 | ||||||||
| FaxNumber: | 7245438616 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 NOLTE DR | ||||||||
| Address2: | |||||||||
| City: | KITTANNING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162017111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245438164 | ||||||||
| FaxNumber: | 7245438616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | UP000235F | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN158159L | 01 | PA | RN LICENSE | OTHER | UP000235F | 01 | PA | CRNP FAMILY PLAN LICENSE# | OTHER |