Provider Demographics
NPI:1790367084
Name:GALL, CHANDRA JANELLE (CCP, LP)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:JANELLE
Last Name:GALL
Suffix:
Gender:F
Credentials:CCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34117-5349
Mailing Address - Country:US
Mailing Address - Phone:574-276-0877
Mailing Address - Fax:
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-624-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000-00273242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist