Provider Demographics
NPI:1598945073
Name:COLLENBORNE, CHARLIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:ANN
Last Name:COLLENBORNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLENE
Other - Middle Name:ANN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:90 HOPE DR BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1000
Mailing Address - Country:US
Mailing Address - Phone:208-828-7281
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32778208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice