Provider Demographics
NPI:1194921965
Name:CHACON, MAYDER (RN)
Entity type:Individual
Prefix:
First Name:MAYDER
Middle Name:
Last Name:CHACON
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 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:
Practice Address - Street 1:8902 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6401
Practice Address - Country:US
Practice Address - Phone:818-830-7033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA583986163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70468FOtherEAPC PROGRAM