Basic Information
| Provider Information | |||||||||
| NPI: | 1639618465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANDRA | ||||||||
| FirstName: | ANGEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 LIFETIME DR | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095418722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 720 WOOD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072682990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | PN687860 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.