Provider Demographics
NPI:1033670773
Name:CHANDLER, CARLISA ANTOINETTE
Entity Type:Individual
Prefix:
First Name:CARLISA
Middle Name:ANTOINETTE
Last Name:CHANDLER
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 1:502 CARDINAL CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1758
Mailing Address - Country:US
Mailing Address - Phone:434-446-5144
Mailing Address - Fax:
Practice Address - Street 1:1127 MARIONS TRL
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:VA
Practice Address - Zip Code:24558-3129
Practice Address - Country:US
Practice Address - Phone:434-579-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62219932347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle