Provider Demographics
NPI:1053691535
Name:WHITLOCK, CHARLES WILLIAM (NURSE PRACTITIONER,)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:WHITLOCK
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER,
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:WILLIAM
Other - Last Name:WIKLE
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER,
Mailing Address - Street 1:19 BRADHURST AVE STE 3100N
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1154
Practice Address - Country:US
Practice Address - Phone:845-431-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-28
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401341363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health