Provider Demographics
NPI:1760740401
Name:WELLS, CHARLA DANIELLE (LPN)
Entity Type:Individual
Prefix:DR
First Name:CHARLA
Middle Name:DANIELLE
Last Name:WELLS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S WASHINGTON ST
Mailing Address - Street 2:APT 1
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7091
Mailing Address - Country:US
Mailing Address - Phone:580-264-0406
Mailing Address - Fax:
Practice Address - Street 1:2530 S COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5519
Practice Address - Country:US
Practice Address - Phone:580-223-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0058148164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse