Healthcare Provider Details

I. General information

NPI: 1407846355
Provider Name (Legal Business Name): ILUMINADA S CHINNETH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ILUMINADA S CALICDAN ARNP

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAG-J, UNIT 45013 BOX 2719
APO AP
96338
JP

IV. Provider business mailing address

USAG-J, UNIT 45013 BOX 2719
APO AP
96338
JP

V. Phone/Fax

Practice location:
  • Phone: 315-263-7832
  • Fax: 315-263-8463
Mailing address:
  • Phone: 315-263-7832
  • Fax: 315-263-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberAP30004756
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: