Healthcare Provider Details

I. General information

NPI: 1114236627
Provider Name (Legal Business Name): CHANDLER D GAVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E CESAR CHAVEZ BLVD # 319
FRESNO CA
93702-3604
US

IV. Provider business mailing address

1617 E SAGINAW WAY SUITE #102
FRESNO CA
93704-4458
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-2382
  • Fax:
Mailing address:
  • Phone: 559-274-0299
  • Fax: 559-225-0716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 209645
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: