MEDICARE: CHARLENE WICHMAN

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1245636463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLENE WICHMAN

Provider Business Mailing Address
First Line	:	6045 S RIDGELINE DR
Second Line	:	APT. K201
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-6978
Country	:	US
Telephone Number	:	330-671-1242
Fax Number	:

Provider Business Practice Location Address
First Line	:	6045 S RIDGELINE DR
Second Line	:	APT. K201
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-6978
Country	:	US
Telephone Number	:	330-671-1242
Fax Number	:

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

Provider Enumeration Date	:	11/16/2014
Last Update Date	:	11/16/2014

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