Provider Demographics
NPI:1245750744
Name:CHATTERTON, CAROLYN GRACE (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:GRACE
Last Name:CHATTERTON
Suffix:
Gender:F
Credentials:DO, MPH
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:GRACE
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 N 12TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1308
Mailing Address - Country:US
Mailing Address - Phone:414-219-4100
Mailing Address - Fax:
Practice Address - Street 1:1020 N 12TH ST STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-219-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8151721207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100287403Medicaid