Provider Demographics
NPI:1124751912
Name:CHARLESWORTH, BRYNN LARA (MD)
Entity type:Individual
Prefix:
First Name:BRYNN
Middle Name:LARA
Last Name:CHARLESWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 HAMLINE STREET
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203
Mailing Address - Country:US
Mailing Address - Phone:701-780-6810
Mailing Address - Fax:
Practice Address - Street 1:725 HAMLINE STREET
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-780-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine