Provider Demographics
NPI:1790464550
Name:CAMPALANS CARVALLO, CARMEN HELENA
Entity Type:Individual
Prefix:
First Name:CARMEN HELENA
Middle Name:
Last Name:CAMPALANS CARVALLO
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 1:1306 FAIRMONT ST NW APT B
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-7069
Mailing Address - Country:US
Mailing Address - Phone:203-522-7490
Mailing Address - Fax:
Practice Address - Street 1:100 GALLATIN ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-7533
Practice Address - Country:US
Practice Address - Phone:844-796-2797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA200001728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant