Basic Information
| Provider Information | |||||||||
| NPI: | 1831235670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDLER | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 5TH ST S | ||||||||
| Address2: | DEPARTMENT 70-6600 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 5TH ST S | ||||||||
| Address2: | DEPARTMENT 70-6600 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | D0064535 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000191600 | 05 | FL | MEDICAID |