Basic Information
Provider Information | |||||||||
NPI: | 1295325140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAMBARD | ||||||||
FirstName: | NICK | ||||||||
MiddleName: | LANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHAMBARD | ||||||||
OtherFirstName: | NICHOLAS | ||||||||
OtherMiddleName: | LANE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR/L | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 275 SE CABOT DR STE A5 | ||||||||
Address2: |   | ||||||||
City: | OAK HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 982773740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3609145504 | ||||||||
FaxNumber: | 3606394079 | ||||||||
Practice Location | |||||||||
Address1: | 275 SE CABOT DR STE A5 | ||||||||
Address2: |   | ||||||||
City: | OAK HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 982773740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3609145504 | ||||||||
FaxNumber: | 3606394079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2021 | ||||||||
LastUpdateDate: | 01/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT.61137403 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.