Provider Demographics
NPI:1053662106
Name:GARRETT, CHANADOLL QUANISHA
Entity Type:Individual
Prefix:
First Name:CHANADOLL
Middle Name:QUANISHA
Last Name:GARRETT
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 1:2500 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:510-667-3005
Practice Address - Street 1:2500 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1005
Practice Address - Country:US
Practice Address - Phone:510-667-3005
Practice Address - Fax:510-667-3005
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program