Basic Information
| Provider Information | |||||||||
| NPI: | 1942552344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDAVONG | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MARILLA CT | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958352431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165240368 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 DOUGLAS BLVD STE 150 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162419844 | ||||||||
| FaxNumber: | 9162419845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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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 | 363LF0000X | 21878 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 21878 | 01 | CA | NP | OTHER | 606698 | 01 | CA | RN | OTHER |