Provider Demographics
NPI:1649868217
Name:CLARK, CHANDRA H (RN, CDCES)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:H
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11106 HAWKES LANE
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824
Mailing Address - Country:US
Mailing Address - Phone:757-327-1817
Mailing Address - Fax:
Practice Address - Street 1:11106 HAWKES LANE
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:VA
Practice Address - Zip Code:23824
Practice Address - Country:US
Practice Address - Phone:757-327-1817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001157171163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty