Provider Demographics
NPI:1245636463
Name:WICHMAN, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WICHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 S RIDGELINE DR
Mailing Address - Street 2:APT. K201
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6978
Mailing Address - Country:US
Mailing Address - Phone:330-671-1242
Mailing Address - Fax:
Practice Address - Street 1:6045 S RIDGELINE DR
Practice Address - Street 2:APT. K201
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6978
Practice Address - Country:US
Practice Address - Phone:330-671-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer