Provider Demographics
NPI:1912596867
Name:CHARLTON, ILEA
Entity Type:Individual
Prefix:
First Name:ILEA
Middle Name:
Last Name:CHARLTON
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:PO BOX 1614
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-1614
Mailing Address - Country:US
Mailing Address - Phone:701-690-5956
Mailing Address - Fax:
Practice Address - Street 1:112 4TH ST SW
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7146
Practice Address - Country:US
Practice Address - Phone:701-690-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker