Basic Information
| Provider Information | |||||||||
| NPI: | 1568050805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | CONSOLACION MONICA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078009 | ||||||||
| FaxNumber: | 2604078009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462223802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176364400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71010626A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.