Provider Demographics
NPI:1508287772
Name:STAAB, CHARLIEY AMBER
Entity Type:Individual
Prefix:
First Name:CHARLIEY
Middle Name:AMBER
Last Name:STAAB
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 1:11307 W 65TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-5514
Mailing Address - Country:US
Mailing Address - Phone:785-577-6326
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST STE 250
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2218
Practice Address - Country:US
Practice Address - Phone:785-577-6326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant