Provider Demographics
NPI:1629214721
Name:SNIPES, CHARLENE KAY (OTR/L)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:KAY
Last Name:SNIPES
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 E KIOWA ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9547
Mailing Address - Country:US
Mailing Address - Phone:602-369-7328
Mailing Address - Fax:
Practice Address - Street 1:3920 E HUNTINGTON DR
Practice Address - Street 2:SUITE A
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-9409
Practice Address - Country:US
Practice Address - Phone:602-369-7328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-20
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0369172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ356396OtherPROVIDER AHCCCS ID NUMBER