Provider Demographics
NPI:1578055471
Name:CHANDLER, FANTASIA IZOLIA (APRN)
Entity Type:Individual
Prefix:
First Name:FANTASIA
Middle Name:IZOLIA
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 CHANSTALAS RD
Mailing Address - Street 2:
Mailing Address - City:SALLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29137-9435
Mailing Address - Country:US
Mailing Address - Phone:803-608-8938
Mailing Address - Fax:
Practice Address - Street 1:575 STONEWALL JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-7250
Practice Address - Country:US
Practice Address - Phone:864-316-8984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21694363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5280Medicaid