Provider Demographics
NPI:1033889647
Name:FIELDS, CHARLA (CHW-C, CPHT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLA
Middle Name:
Last Name:FIELDS
Suffix:
Gender:F
Credentials:CHW-C, CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 E HINES ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1277
Mailing Address - Country:US
Mailing Address - Phone:417-735-0055
Mailing Address - Fax:
Practice Address - Street 1:1173 E HINES ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1277
Practice Address - Country:US
Practice Address - Phone:417-735-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011006391183700000X
MO13248172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No183700000XPharmacy Service ProvidersPharmacy Technician