Provider Demographics
NPI:1922218866
Name:CHACON, CAROLE DENISE (CCCE, CLE, IBCLC)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:DENISE
Last Name:CHACON
Suffix:
Gender:F
Credentials:CCCE, CLE, IBCLC
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:
Other - Last Name:CHACON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCCE, CLE, IBCLC
Mailing Address - Street 1:15245 TUBA ST
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-2701
Mailing Address - Country:US
Mailing Address - Phone:818-642-7629
Mailing Address - Fax:
Practice Address - Street 1:15245 TUBA ST
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2701
Practice Address - Country:US
Practice Address - Phone:818-642-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10623355174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1843OtherCAPPA
NC10623355OtherIBCLE