Provider Demographics
NPI:1437895752
Name:VIDAL, CHANDELLE
Entity Type:Individual
Prefix:
First Name:CHANDELLE
Middle Name:
Last Name:VIDAL
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 1:4416 SW 163RD PSGE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4577
Mailing Address - Country:US
Mailing Address - Phone:954-531-5615
Mailing Address - Fax:
Practice Address - Street 1:10570 NW 27TH ST # H102B
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2104
Practice Address - Country:US
Practice Address - Phone:786-234-9056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula