Provider Demographics
NPI:1063687317
Name:CHALK, LAURA BETH (PCNS)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:BETH
Last Name:CHALK
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GOVERNOR ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3246
Mailing Address - Country:US
Mailing Address - Phone:401-383-4848
Mailing Address - Fax:401-383-4811
Practice Address - Street 1:208 GOVERNOR ST FL 2
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3246
Practice Address - Country:US
Practice Address - Phone:401-383-4848
Practice Address - Fax:401-383-4811
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00352364SP0809X
RIMW00060367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife