Healthcare Provider Details

I. General information

NPI: 1699238675
Provider Name (Legal Business Name): MAMTA CHANDAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CABARRUS AVE E STE 200
CONCORD NC
28025-3781
US

IV. Provider business mailing address

101 CABARRUS AVE E STE 200
CONCORD NC
28025-3781
US

V. Phone/Fax

Practice location:
  • Phone: 888-849-7379
  • Fax: 855-857-7333
Mailing address:
  • Phone: 888-849-7379
  • Fax: 855-857-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5011646
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: