Provider Demographics
NPI:1912308784
Name:PROVOST, CHETTIA (DC)
Entity Type:Individual
Prefix:
First Name:CHETTIA
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 N PITT ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5600
Mailing Address - Country:US
Mailing Address - Phone:703-739-0456
Mailing Address - Fax:703-739-0032
Practice Address - Street 1:1240 N PITT ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5600
Practice Address - Country:US
Practice Address - Phone:703-739-0456
Practice Address - Fax:703-739-0032
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor