MEDICARE: PATRICE CHANCE MALENA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024055685	VA

General Provider Information

NPI Number	:	1508863853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICE CHANCE MALENA FNP

Provider Business Mailing Address
First Line	:	856 J CLYDE MORRIS BLVD
Second Line	:	SUITE A
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23601-1318
Country	:	US
Telephone Number	:	757-594-4006
Fax Number	:	757-594-2195

Provider Business Practice Location Address
First Line	:	12700 MCMANUS BLVD
Second Line	:	SUITE 102 A
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-4407
Country	:	US
Telephone Number	:	757-874-8696
Fax Number	:	757-872-9904

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	12/18/2008

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