Provider Demographics
NPI:1457861726
Name:CHALK, MIRANDA D (RN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:D
Last Name:CHALK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7281 NEW CUT RD
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-7157
Mailing Address - Country:US
Mailing Address - Phone:864-804-3002
Mailing Address - Fax:864-485-3115
Practice Address - Street 1:199 SPARTANBURG HWY
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1601
Practice Address - Country:US
Practice Address - Phone:864-804-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0717253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care