Basic Information
Provider Information | |||||||||
NPI: | 1619213451 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHADWICK | ||||||||
FirstName: | MARGOT | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 610 S BURDICK ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693813700 | ||||||||
FaxNumber: | 2693813810 | ||||||||
Practice Location | |||||||||
Address1: | 610 S BURDICK ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693813700 | ||||||||
FaxNumber: | 2693813810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2012 | ||||||||
LastUpdateDate: | 08/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704147243 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 163WP0809X | 4704147243 | MI | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.