Healthcare Provider Details

I. General information

NPI: 1144197278
Provider Name (Legal Business Name): ERICA LYNN CHARBONEAU
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 PITCHER PARK SE
DEVILS LAKE ND
58301-3962
US

IV. Provider business mailing address

419 PITCHER PARK SE
DEVILS LAKE ND
58301-3962
US

V. Phone/Fax

Practice location:
  • Phone: 701-230-7221
  • Fax:
Mailing address:
  • Phone: 701-230-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: