Healthcare Provider Details

I. General information

NPI: 1689134686
Provider Name (Legal Business Name): CARLY HANNAH CHAMBERLAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 14TH ST
WILMINGTON DE
19801-1013
US

IV. Provider business mailing address

501 W 14TH ST
WILMINGTON DE
19801-1013
US

V. Phone/Fax

Practice location:
  • Phone: 302-320-4410
  • Fax: 302-428-4078
Mailing address:
  • Phone: 302-320-4410
  • Fax: 302-428-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberC2-0024178
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC2-0024178
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: