MEDICARE: CHARLESZETTA C GULLEDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	NA0060041468	TX

General Provider Information

NPI Number	:	1164142923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLESZETTA C GULLEDGE

Provider Business Mailing Address
First Line	:	5116 E OUTER DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-3402
Country	:	US
Telephone Number	:	682-294-5009
Fax Number	:

Provider Business Practice Location Address
First Line	:	5116 E OUTER DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-3402
Country	:	US
Telephone Number	:	682-294-5009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2022
Last Update Date	:	08/31/2022

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Directions to “ CHARLESZETTA C GULLEDGE ” Practice Location

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