Provider Demographics
NPI:1104337179
Name:BURNSIDE, CHANDRA JEANNE (RN)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:JEANNE
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4654A 36TH STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206
Mailing Address - Country:US
Mailing Address - Phone:703-946-0708
Mailing Address - Fax:
Practice Address - Street 1:4654A 36TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206
Practice Address - Country:US
Practice Address - Phone:703-946-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001260026163WX0003X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient