Provider Demographics
NPI:1679141113
Name:CHARDON, MARIE LATANE (PHD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LATANE
Last Name:CHARDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-6615
Mailing Address - Country:US
Mailing Address - Phone:804-380-1609
Mailing Address - Fax:
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:MLC 7039
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-517-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program