Provider Demographics
NPI:1275685356
Name:SURBAUGH, CHARLENE (RN, FA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:SURBAUGH
Suffix:
Gender:F
Credentials:RN, FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1808
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1808
Mailing Address - Country:US
Mailing Address - Phone:208-734-3455
Mailing Address - Fax:208-733-7389
Practice Address - Street 1:562 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5029
Practice Address - Country:US
Practice Address - Phone:208-734-3455
Practice Address - Fax:208-733-7389
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN14523163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse