Basic Information
| Provider Information | |||||||||
| NPI: | 1003968884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABLAO-CHANTHAVICHITH | ||||||||
| FirstName: | FLORDELIZA | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2876 GUARDIAN LN | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234527327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574635240 | ||||||||
| FaxNumber: | 7574636572 | ||||||||
| Practice Location | |||||||||
| Address1: | 3235 ACADEMY AVE | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576869300 | ||||||||
| FaxNumber: | 7576861514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024167161 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1003968884 | 05 | VA | MEDICAID |