Provider Demographics
NPI:1467701664
Name:CHACONAS, AMANDA IRIS (DNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:IRIS
Last Name:CHACONAS
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:IRIS
Other - Last Name:VERCOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1016 W UNIVERSITY AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2996
Mailing Address - Country:US
Mailing Address - Phone:928-226-1530
Mailing Address - Fax:
Practice Address - Street 1:1016 W UNIVERSITY AVE STE 206
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2996
Practice Address - Country:US
Practice Address - Phone:928-226-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN172540163W00000X
AZTEMP281408363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1467701664Medicaid