Healthcare Provider Details

I. General information

NPI: 1881180222
Provider Name (Legal Business Name): EYMY DIANA CHACON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 01/07/2022
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 CAMPBELL AVE
WEST HAVEN CT
06516-3786
US

IV. Provider business mailing address

3495 PIEDMONT RD NE BLDG 93
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-0034
  • Fax:
Mailing address:
  • Phone: 404-949-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN285274
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: