Provider Demographics
NPI:1245925122
Name:CHARLES, CHLOE CORINNE
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:CORINNE
Last Name:CHARLES
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 1:1137 E 6720 S APT 32
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-7223
Mailing Address - Country:US
Mailing Address - Phone:978-732-8067
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
UT11121475-4405363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer