Provider Demographics
NPI:1104522796
Name:SMALL, CHARLETTE A
Entity type:Individual
Prefix:
First Name:CHARLETTE
Middle Name:A
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 COTTONWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ABSAROKEE
Mailing Address - State:MT
Mailing Address - Zip Code:59001-6211
Mailing Address - Country:US
Mailing Address - Phone:406-699-0042
Mailing Address - Fax:
Practice Address - Street 1:45 COTTONWOOD WAY
Practice Address - Street 2:
Practice Address - City:ABSAROKEE
Practice Address - State:MT
Practice Address - Zip Code:59001-6211
Practice Address - Country:US
Practice Address - Phone:406-328-7448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT212613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine