Provider Demographics
NPI:1205158037
Name:CHARLESWORTH, KELLY RENEE
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:CHARLESWORTH
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 1:1238 POLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-7756
Mailing Address - Country:US
Mailing Address - Phone:814-937-4614
Mailing Address - Fax:
Practice Address - Street 1:1149 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-1607
Practice Address - Country:US
Practice Address - Phone:814-937-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-21
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP046170L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist