Healthcare Provider Details

I. General information

NPI: 1689129116
Provider Name (Legal Business Name): DIANA CHARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 S GOULD ST
SHERIDAN WY
82801-6304
US

IV. Provider business mailing address

1333 W 5TH ST STE 110
SHERIDAN WY
82801-2752
US

V. Phone/Fax

Practice location:
  • Phone: 307-675-2690
  • Fax:
Mailing address:
  • Phone: 307-675-2650
  • Fax: 307-675-2651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27134.1541
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: