Provider Demographics
NPI:1164142923
Name:GULLEDGE, CHARLESZETTA C
Entity Type:Individual
Prefix:
First Name:CHARLESZETTA
Middle Name:C
Last Name:GULLEDGE
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 1:5116 E OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3402
Mailing Address - Country:US
Mailing Address - Phone:682-294-5009
Mailing Address - Fax:
Practice Address - Street 1:5116 E OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3402
Practice Address - Country:US
Practice Address - Phone:682-294-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA0060041468376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide