Provider Demographics
NPI:1982143665
Name:CHAN, JOSEPHINE (DOM, AP)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 CORNER GLEN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32820-1952
Mailing Address - Country:US
Mailing Address - Phone:407-758-0179
Mailing Address - Fax:407-602-9042
Practice Address - Street 1:924 N MAGNOLIA AVE STE 332
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3852
Practice Address - Country:US
Practice Address - Phone:407-758-0179
Practice Address - Fax:407-602-0942
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2021-02-12
Deactivation Date:2021-01-12
Deactivation Code:
Reactivation Date:2021-02-12
Provider Licenses
StateLicense IDTaxonomies
FL3797171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107565300Medicaid