Provider Demographics
NPI:1316556277
Name:CHAMBERLAIN, CARISSA ELLEN (CPM, LM)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ELLEN
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:ELLEN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 BOYDSTUN ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3403
Mailing Address - Country:US
Mailing Address - Phone:208-615-2273
Mailing Address - Fax:208-630-6303
Practice Address - Street 1:505 BOYDSTUN ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3403
Practice Address - Country:US
Practice Address - Phone:208-615-2273
Practice Address - Fax:208-630-6303
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-105176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife