Healthcare Provider Details

I. General information

NPI: 1174934269
Provider Name (Legal Business Name): CHARLYN K WARE MS RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHARLYN K FARGO

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 1100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-4735
Mailing address:
  • Phone: 217-545-8000
  • Fax: 844-470-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.001664
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: