Provider Demographics
NPI:1508529249
Name:CHAVOUS, LAWANDA
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:
Last Name:CHAVOUS
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 1:1835 MERIBROOK RD
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-2014
Mailing Address - Country:US
Mailing Address - Phone:484-369-7690
Mailing Address - Fax:
Practice Address - Street 1:1835 MERIBROOK RD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19151-2014
Practice Address - Country:US
Practice Address - Phone:484-369-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA60543601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA834226305Medicaid