Provider Demographics
NPI:1083212757
Name:STALTARE, CHARLIEN ANNE
Entity Type:Individual
Prefix:
First Name:CHARLIEN
Middle Name:ANNE
Last Name:STALTARE
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 1:46762 GRAHAM COVE SQ
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-7535
Mailing Address - Country:US
Mailing Address - Phone:571-217-5685
Mailing Address - Fax:
Practice Address - Street 1:46762 GRAHAM COVE SQ
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-7535
Practice Address - Country:US
Practice Address - Phone:571-217-5685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4875133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist