Provider Demographics
NPI:1083377204
Name:DURGELOH, CARLIE LEANN
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:LEANN
Last Name:DURGELOH
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 1:526 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-1619
Mailing Address - Country:US
Mailing Address - Phone:509-720-3062
Mailing Address - Fax:
Practice Address - Street 1:526 5TH ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-1619
Practice Address - Country:US
Practice Address - Phone:509-720-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer