Provider Demographics
NPI:1457707572
Name:LADIN, CHANRACHNA
Entity Type:Individual
Prefix:
First Name:CHANRACHNA
Middle Name:
Last Name:LADIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANRACHNA
Other - Middle Name:
Other - Last Name:THAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3119 WOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2668
Mailing Address - Country:US
Mailing Address - Phone:888-277-3832
Mailing Address - Fax:
Practice Address - Street 1:3119 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2668
Practice Address - Country:US
Practice Address - Phone:888-277-3832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016111363L00000X
MO2016015966363LF0000X
PASP022128363LF0000X
WI11262-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily