Provider Demographics
NPI:1346886504
Name:CLYBURN, CHAZ LAMAR
Entity Type:Individual
Prefix:
First Name:CHAZ
Middle Name:LAMAR
Last Name:CLYBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 SHADY GROVE LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1787
Mailing Address - Country:US
Mailing Address - Phone:757-800-7806
Mailing Address - Fax:
Practice Address - Street 1:5217 SHADY GROVE LN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1787
Practice Address - Country:US
Practice Address - Phone:757-800-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMEBS3R6ROtherAETNA