Provider Demographics
NPI:1952976938
Name:CHARTRAND, TALESA MARIE (PHD, STUDENT DOCTOR)
Entity type:Individual
Prefix:MISS
First Name:TALESA
Middle Name:MARIE
Last Name:CHARTRAND
Suffix:
Gender:F
Credentials:PHD, STUDENT DOCTOR
Other - Prefix:
Other - First Name:TALESA
Other - Middle Name:MARIE
Other - Last Name:CHARTRAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6650 THURSTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7154
Mailing Address - Country:US
Mailing Address - Phone:541-321-8622
Mailing Address - Fax:
Practice Address - Street 1:6650 THURSTON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-7154
Practice Address - Country:US
Practice Address - Phone:541-321-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR458425390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-5LL-18803OtherLICENSE NUMBER