Provider Demographics
NPI:1679138507
Name:RICHARDS, CHANDRA
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:RICHARDS
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 1:2137 LEAHY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1124
Mailing Address - Country:US
Mailing Address - Phone:231-578-0656
Mailing Address - Fax:
Practice Address - Street 1:2137 LEAHY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1124
Practice Address - Country:US
Practice Address - Phone:231-578-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 2470A2800X
MI4703098161164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician