Provider Demographics
NPI:1114236627
Name:GAVIN, CHANDLER D
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:D
Last Name:GAVIN
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 1:1617 E SAGINAW WAY
Mailing Address - Street 2:SUITE #102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-4458
Mailing Address - Country:US
Mailing Address - Phone:559-274-0299
Mailing Address - Fax:559-225-0716
Practice Address - Street 1:4411 E KINGS CANYON RD # 319
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 209645164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse