Healthcare Provider Details

I. General information

NPI: 1790367084
Provider Name (Legal Business Name): CHANDRA JANELLE GALL CCP, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 7TH ST N
NAPLES FL
34102-5754
US

IV. Provider business mailing address

3305 15TH AVE SW
NAPLES FL
34117-5349
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-5000
  • Fax:
Mailing address:
  • Phone: 574-276-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number1000-00273
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: