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 1:4618 CHESTER AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3645
Mailing Address - Country:US
Mailing Address - Phone:925-876-1105
Mailing Address - Fax:
Practice Address - Street 1:2600 N AMERICAN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3413
Practice Address - Country:US
Practice Address - Phone:215-739-2669
Practice Address - Fax:215-739-5879
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR19683600163W00000X
DEL1-0052335163W00000X
PARN694705163W00000X
PASP021192363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse