Provider Demographics
NPI:1114632130
Name:CLARK, CHANDLER (NP)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 LANIER PL NW APT 5
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2599
Mailing Address - Country:US
Mailing Address - Phone:913-226-0342
Mailing Address - Fax:
Practice Address - Street 1:24440 STONE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2247
Practice Address - Country:US
Practice Address - Phone:571-349-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185283363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal