Provider Demographics
NPI:1477123701
Name:CHAMBERS, KAMIYAL SHAVONDAR (NA)
Entity Type:Individual
Prefix:
First Name:KAMIYAL
Middle Name:SHAVONDAR
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4919 ALBEMARLE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6653
Mailing Address - Country:US
Mailing Address - Phone:980-447-3070
Mailing Address - Fax:704-448-2050
Practice Address - Street 1:7701 CREEKRIDGE RD APT 1005
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-0175
Practice Address - Country:US
Practice Address - Phone:980-447-3070
Practice Address - Fax:704-448-2080
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC330338376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC86-1626733Medicaid