Provider Demographics
NPI:1639644693
Name:DAVIS, CHALANDRA
Entity Type:Individual
Prefix:
First Name:CHALANDRA
Middle Name:
Last Name:DAVIS
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:PO BOX 1924
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-1924
Mailing Address - Country:US
Mailing Address - Phone:352-448-5415
Mailing Address - Fax:
Practice Address - Street 1:3804 WINDY MEADOW DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-6102
Practice Address - Country:US
Practice Address - Phone:352-448-5415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities