Provider Demographics
NPI:1083744841
Name:CHARLES, SALLIE H (NP)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:H
Last Name:CHARLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SALLIE
Other - Middle Name:ANN HONORA
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:580 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3712
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO63790363L00000X
CO4399363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45000239Medicaid
015915OtherKAISER-COMMERCIAL NUMBER
CO45000239Medicaid
COCOA105402Medicare PIN
015915OtherKAISER-COMMERCIAL NUMBER