Provider Demographics
NPI:1417676164
Name:CHAGOLLA, YESENIA
Entity Type:Individual
Prefix:
First Name:YESENIA
Middle Name:
Last Name:CHAGOLLA
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 1:15525 N 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5820
Mailing Address - Country:US
Mailing Address - Phone:877-809-5092
Mailing Address - Fax:
Practice Address - Street 1:15525 N 83RD AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5820
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator