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General NPI Number Information
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NPI Number | 1134654338
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Entity Type | Organization
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Legal Business Name | CHESTNUT FAMILY PRACTICE, PLLC
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Dates
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Enumeration Date | 04/25/2017
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Last Update Date | 05/01/2017
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Provider Practice Location Address
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Address Line | 1013 CHESTNUT LN SUITE 110
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City | MATTHEWS
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State | NC
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Zip | 28104-8566
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Country | US
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Telephone | 704-268-9267
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Fax |
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Provider Business Mailing Address
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Address Line | 1013 CHESTNUT LN SUITE 110
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City | MATTHEWS
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State | NC
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Zip | 28104-8566
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Country | US
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Telephone | 704-268-9267
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Fax | 801-730-3501
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Authorized Official
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Title or Position | OWNER
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Name | DR. SUSAN ELISE LADD-SNIVELY
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Credential | MD
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Telephone | 704-268-9267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 220342
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License Number State | NC
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