Healthcare Provider Details

I. General information

NPI: 1275986986
Provider Name (Legal Business Name): JAESOON KATIE CHA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 FULLER ST
FORT HUACHUCA AZ
85613-1624
US

IV. Provider business mailing address

716 FULLER ST
FORT HUACHUCA AZ
85613-1624
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9113
  • Fax: 520-533-5148
Mailing address:
  • Phone: 520-533-9113
  • Fax: 520-533-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberVN221010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: