Provider Demographics
NPI:1669679502
Name:NETTLETON, CHARLA MAE (PT)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:MAE
Last Name:NETTLETON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11521 ROAD G
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-9569
Mailing Address - Country:US
Mailing Address - Phone:970-564-9457
Mailing Address - Fax:970-564-9457
Practice Address - Street 1:1221 N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2218
Practice Address - Country:US
Practice Address - Phone:970-564-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6820225100000X
NM2566225100000X
AZ6242225100000X
UT6279685-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist