Basic Information
| Provider Information | |||||||||
| NPI: | 1174031579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | CARMEN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 S ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | FLAT ROCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287319447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2869261788 | ||||||||
| FaxNumber: | 8282332594 | ||||||||
| Practice Location | |||||||||
| Address1: | 571 S ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | FLAT ROCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926178 | ||||||||
| FaxNumber: | 8282332594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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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 | 238483 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5010206 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MC4685840 | 01 | NC | DEA | OTHER | 5010206 | 01 | NC | NURSE PRACTITIONER- FAMILY | OTHER | 238483 | 01 | NC | RN | OTHER |