Provider Demographics
NPI:1780267864
Name:HUBBARD, CHARISH LANE
Entity type:Individual
Prefix:
First Name:CHARISH
Middle Name:LANE
Last Name:HUBBARD
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 1:1143 W 150 N
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-5558
Mailing Address - Country:US
Mailing Address - Phone:208-339-2952
Mailing Address - Fax:
Practice Address - Street 1:1143 W 150 N
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-5558
Practice Address - Country:US
Practice Address - Phone:208-339-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12373948-8901367500000X
ID42059163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse